565800734-6-19-2023-29-AS-ECAS-CSXSBC-20230619134343

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565800734
Report Date: 06/19/2023
Date Signed: 06/19/2023 01:44:24 PM

Document Has Been Signed on 06/19/2023 01:44 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 ROYALE		FACILITY NUMBER:	565800734
ADMINISTRATOR:	INGA JAKOBOVICH		FACILITY TYPE:	740
ADDRESS:	190 EAST HILLCREST DRIVE		TELEPHONE:	(805) 371-0035
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	145	CENSUS: 85	DATE:	06/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Inga Jackobovich		TIME COMPLETED:	01:50 PM

NARRATIVE

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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a required annual visit at 9:45 a.m. The LPA was greeted by staff and informed them of the reason for the visit. Administrator Inga Jakobovich was at the facility and met with the LPA.

The LPA and the Administrator began the tour of the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: The LPA began the inspection in the kitchen/food service area at 10:25 a.m. Knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 10:31 a.m., the LPA and Administrator observed expired/moldy lettuce heads inside a bin in the refrigerator. At 10:37 a.m. the LPA and Administrator observed a box containing multiple moldy tomatoes in the pantry and a can of expired prune juice with an expiration date of 12/8/2022 was also observed. All items were discarded by the administrator upon discovery. The Administrator indicated these items were delivered recently but would ensure all items are checked. It was additionally discussed with the administrator that if any taps in the industrial kitchen are delivering water temps above 125 degrees F to ensure that there is a warning sign indicating that sink delivers hot water above 125 degrees F.

COMMON AREAS: Units designated for assisted living residents are on all three floors. There was hands-free hand sanitizer interspersed throughout the common grounds. The LPA toured all three floors and common spaces throughout the facility. Activity rooms and common spaces were clean and in good repair. No obstructions and/or tripping hazards observed. Fire extinguishers were last inspected on 11/17/2022.

OUTDOOR AREA: The LPA toured the courtyard, where there was appropriate outdoor furniture, with a covered shaded area for residents. There is an area for residents to play games. Parking is available for residents and visitors. **Continued on LIC 809-C**

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

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 06/19/2023 01:44 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: 06/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above as the ceiling in bedroom 204 was observed to have water damage which poses an immediate health and safety risk to persons in care.
	POC Due Date: 06/20/2023
	Plan of Correction
1 2 3 4	Licensee agreed to the do the following: 1. Submit a plan of action on how the water damage will be assesed and if the resident needs to be relocated to another room what procedure will take place. No later than the end of the day 6/20/2023.

Type A

Section Cited

CCR

87555(b)(8)

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as moldy lettuce, moldy tomatoes and expired prune juice was discivered which poses an immediate health and safety risk to persons in care.
	POC Due Date: 06/20/2023
	Plan of Correction
1 2 3 4	Licensee agreed to do the following: 1. Dispose of all expired food items. Plan of correction met at the time of the visit. 2. Conduct an audit of all perishable and non perishable foods to ensure quality and check expiration dates. Advise CCL when it was conducted no later than 6/23/2023.

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/19/2023 01:44 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: 06/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as taps throughout the facility were found to be delivering hot water up to 125.4 degrees F which poses a potential health and safety risk to persons in care.
	POC Due Date: 06/23/2023
	Plan of Correction
1 2 3 4	The licensee agreed to do the following: 1. Do a check of water temps and make necessary adjustments to ensure taps are not deleivering hot water above 120 degrees F. At inform CCL when this has been completed no later than 6/23/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

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: 06/19/2023

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BEDROOMS: Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. LPAs observed a random selection of rooms on all floors. Bedroom 204 was observed to have visible water damage on the ceiling. LPA conducted water temperature checks between 11:10 a.m. through 11:53 a.m., and the hot water measured ranged between 118.9 degrees F to 125.4 degrees F. Restrooms were fully stocked with paper towels and soap. LPA observed a random selection of resident bathrooms on all floors.

Due to time constraints, the LPA will return at a later date to complete the inspection.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

LIC809 (FAS) - (06/04)

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