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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561704040
Report Date: 03/20/2024
Date Signed: 03/20/2024 03:06:25 PM

Document Has Been Signed on 03/20/2024 03:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:SENIOR CONCERNS ADULT DAY SUPPORT CENTERFACILITY NUMBER:
561704040
ADMINISTRATOR:ANDREA GALLAGHERFACILITY TYPE:
775
ADDRESS:401 HODENCAMP RDTELEPHONE:
(805) 497-0189
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 75CENSUS: 24DATE:
03/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:Martha Shapiro, Program DirectorTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst(LPA), Christine Yee, conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool and met with Martha Shapiro, Program Director. The reason for today's visit was explained.

The facility is a single storey commercial building consisting of 3 large program areas, conference rooms, offices, a dining room, a kitchen, storage areas, staff lounge and 8 single bathrooms with a toilet and a sink. The facility is fire cleared for 60 Non-Ambulatory and 15 Ambulatory clients.

On today's visit, LPA Yee reviewed five(5) client files, seven(7) staff files and reviewed the following four(4) domains: Operational Requirement, Staffing, Clients Rights - Information and Food Service. The following were observed on today's visit:
  • Per review of the 5 client files, Client #1, Client #2 and Client #3 have attended the facility for more than 30 days and do not have a current Appraisal/Needs and Service Plan in their files.
  • Per review of the 7 staff files, Staff #5 and Staff #7 did not have evidence of current first aid training maintained in their files.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 3

Exit interview was conducted, APPEALS RIGHTS were discussed and a copy was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/20/2024 03:06 PM - It Cannot Be Edited


Created By: Christine Yee On 03/20/2024 at 02:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SENIOR CONCERNS ADULT DAY SUPPORT CENTER
FACILITY NUMBER: 561704040

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82075(f)
Health-Related Services f) Staff responsible for providing direct care and supervision shall receive and maintain current training in first aid and cardiopulmonary resuscitation from persons qualified by agencies including, but not limited to, the American Red Cross.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 7 staff files reviewed, Staff #5 and Staff #7 did not evidentce of current first aid training maintained in their files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2024
Plan of Correction
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Licensee will review all staff files to ensure that all staff have received current first aid training and evidence of the training is maintained in their files for Department review by 3/27/24.
Type B
Section Cited
CCR
82068.2(b)
82068.2 Needs and Services Plan (b) If the client is to be admitted and has no restricted health condition(s) as specified in Section 82092, then, no later than 30 days after admission, the licensee shall complete a written Needs and Services Plan

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out 5 client files reviewed, Client #1(DOA 8/30/23), Client #2(DOA 1/28/24) and Client #3(DOA 1/29/24) did not have a completed Appraisal/Needs and Service Plan in place as of this visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2024
Plan of Correction
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Licensee will will review all client files to ensure that clients have a completed Appraisal/Needs and Services Plan in their file to ensure that their needs are being met by 3/27/24
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024


LIC809 (FAS) - (06/04)
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