565801074-3-9-2022-29-AS-JROS-CCCTXV-20220309140746

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801074
Report Date: 03/09/2022
Date Signed: 03/09/2022 02:09:02 PM

Document Has Been Signed on 03/09/2022 02:09 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:	CRESTWOOD VILLA II		FACILITY NUMBER:	565801074
ADMINISTRATOR:	RAIMONDA BANAKIENE		FACILITY TYPE:	740
ADDRESS:	452 HEIDELBERG AVENUE		TELEPHONE:	(805) 639-0439
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY:	6	CENSUS: 5	DATE:	03/09/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Raimonda Banakiene		TIME COMPLETED:	02:07 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) JoAnn Rosales conducted a Required 1 - Year visit to this facility. LPA met with Administrator Raimonda Banakiene. LPA conducted a facility tour to inspect for infection control practices. Infection control practices were discussed with the Administrator. An inspection of the common areas, resident rooms and restrooms were conducted. LPA observed hot water temperature at 122.8 and 111.8 degrees F. in resident bathrooms. There is an adequate amount of perishable and non-perishable food. PPE supplies were observed. LPA observed the fire extinguisher fully charged. The smoke detectors and carbon monoxide detectors were tested and operable. LPA observed appropriate lighting in residents rooms. LPA observed medications in locked medication closet. Outdoor area toured- passageways are free of obstruction. LPA reviewed resident records. During facility tour at 12:38 pm with Administrator LPA observed shampoo and body wash in resident bathroom accessible to residents. During facility tour at 12:51 pm with Administrator LPA observed hot water temperature at 122.8 degrees in resident bathroom. During facility tour at 12:43 pm with Administrator LPA observed disinfectant wipes and Lysol disinfectant spray in an unlocked closet accessible to residents. During facility tour at 12:46 pm with Administrator LPA observed outside gate not self closing. Continued on 809C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022

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: CRESTWOOD VILLA II	FACILITY NUMBER: 565801074
	VISIT DATE: 03/09/2022

NARRATIVE

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During facility tour at 12:49 pm with Administrator LPA observed deodorant, shaving cream, lotion, calmoseptine ointment and toothpaste in an unlocked cabinet in resident bathroom accessible to residents.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted, todays reports and appeal rights were reviewed and emailed to the Administrator.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/09/2022 02:09 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: CRESTWOOD VILLA II	FACILITY NUMBER: 565801074
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/09/2022

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
1 2 3 4	Based on LPA's observation, the licensee did not comply with the section cited above as the hot water temperature in resident bathroom read at 122.8 degrees F. which poses an immediate health and safety risk to persons in care.
	POC Due Date: 03/09/2022
	Plan of Correction
1 2 3 4	Administrator turned down water heater temperature during facility visit.

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observations and record review, the licensee did not comply with the section cited above as toxic substances were accessible to residents which poses an immediate health risk to persons in care.
	POC Due Date: 03/09/2022
	Plan of Correction
1 2 3 4	Staff placed items in an inaccesible location during facility visit. Administrator stated that they will provide documentation of staff training regarding 87705(f)(2) to CCL by 3/18/22.

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	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 03/09/2022 02:09 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: CRESTWOOD VILLA II	FACILITY NUMBER: 565801074
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(h)

Care of Persons with Dementia

(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation and record review, the licensee did not comply with the section cited above as one of the outside gates is not self closing which poses a potential safety risk to persons in care.
	POC Due Date: 03/18/2022
	Plan of Correction
1 2 3 4	Administrator stated that they will provide documentation of outside gate self-closing to CCL by 3/18/22.

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022

LIC809 (FAS) - (06/04)

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