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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800734
Report Date: 06/18/2022
Date Signed: 06/18/2022 12:27:29 PM


Document Has Been Signed on 06/18/2022 12:27 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:HILLCREST ROYALEFACILITY NUMBER:
565800734
ADMINISTRATOR:INGA JAKOBOVICHFACILITY TYPE:
740
ADDRESS:190 EAST HILLCREST DRIVETELEPHONE:
(805) 371-0035
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:145CENSUS: 94DATE:
06/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Inga JakobovichTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at 8:45 a.m. This annual has a specific emphasis on infection control practices and procedures. The last annual conducted at this facility was on 04/18/2019. Upon entering the facility, the LPA observed four (4) staff not wearing masks. The Administrator, Inga Jakobovich arrived at 9:25 a.m. and was explained the reason for today's visit. Entrance interview conducted.

At 9:30 a.m., the LPA and Administrator began a physical plant tour to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

The facility's dining room and kitchen were observed. LPA observed facility had a sufficient supply of perishable and non-perishable food and food was stored at appropriate temperatures. All knives and sharps are locked inaccessible to residents. A random selection of four (4) resident bedrooms were observed. The LPA observed the resident bedrooms, which were furnished appropriately. Observed inside each room was a bed with clean linens, a nightstand, and sufficient lighting. The LPA observed the restrooms to be clean, sanitary and in operating condition with grab bars and non-skid mats inside the shower. The water temperature was tested on each of the three floor levels. Level one bathroom measured 116.6 degrees Fahrenheit, second level bathrooms measured at 100 degrees Fahrenheit and 104 degrees Fahrenheit, and third level bathroom measured 105.8 degrees Fahrenheit. Fire extinguishers observed were fully charged and last serviced on 11/21/2021. At 9:59 a.m., the LPA observed the medication room, the door does not lock making all medication accessible to residents in care. The Administrator called the maintenance worker to have fixed at the time of visit.

...Continued on LIC 809C...
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: HILLCREST ROYALE
FACILITY NUMBER: 565800734
VISIT DATE: 06/18/2022
NARRATIVE
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...Continued from LIC 809...

During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. The LPA observed appropriate signage which promoted good hand hygiene, physical distancing, symptoms of COVID-19. The Administrator printed CDSS PINS pertaining to visitation guidelines and posted in an easily accessible area for both residents and visitors at the time of visit.

The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE). The facility is in compliance regarding the requirements for indoor and outdoor visitation. The facility was cleared by the Ventura Department of Public Health from their recent Covid-19 Outbreak on 06/09/2022.

Pursuant to Title 22, California Code of Regulations, the following deficiencies will be cited (refer to LIC 9099-D)

Exit interview conducted. Appeal Rights discussed. A copy of this report was sent via email to Administrator.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 06/18/2022 12:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: HILLCREST ROYALE

FACILITY NUMBER: 565800734

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 06/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above as the Level 2 resident's restroom faucets deliver hot water measured at 100 and 104 degrees Fahrenheit, which poses an immediate health and safety risk to persons in care.
POC Due Date: 06/24/2022
Plan of Correction
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The Administrator adjusted the thermostat during time of visit and has agreed to submit a hot water temperature log for seven (7) days to show that the hot water is being maintained between temperatures 105- and 120-degrees Fahrenheit.
Type A
Section Cited
CCR
87468.1(a)(2)
87468.1(a)(2) Personal Rights of Residents in All Facilities ...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above as four (4) staff were observed not wearing masks/face coverings in common areas, which poses an immediate health, safety, and personal rights risk to persons in care.
POC Due Date: 06/24/2022
Plan of Correction
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The Administrator has agreed to immediately notify all staff to wear masks at all times in the facility. Administrator will hold a training with all staff about proper mask-wearing and COVID-19 prevention protocol, and provide training records to CCL by 6/24/2022L

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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 06/18/2022 12:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: HILLCREST ROYALE

FACILITY NUMBER: 565800734

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 06/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)

87465(h)(2) Incidental Medical and Dental Care Services. Centrally stored medications shall be kept in a safe locked place that is not accessible to persons other than employees responsible for the supervision of the medication.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above as the lock to the medication room did not lock, which poses an immediate health and safety risk to persons in care.
POC Due Date: 06/24/2022
Plan of Correction
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The Administrator called the maintenance worker and had door lock fixed at the time of visit. Administrator stated that she will conduct staff training regarding regulation 87465 (h)(2) and will provide documentation of training to CCL by 6/24/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5