565801074-3-21-2024-29-AS-ECOZ-D3KVPN-20240321163701

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801074
Report Date: 03/21/2024
Date Signed: 03/21/2024 04:38:43 PM

Document Has Been Signed on 03/21/2024 04:38 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:	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: 6	DATE:	03/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Raimonda Banakiene		TIME COMPLETED:	04:45 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) Esther Cortez arrived at the facility unannounced to conduct a required annual visit at 01:45 p.m. The LPA met with administrator Raimonda Banakiene and informed them of the reason for the visit. At 01:52 p.m. the LPA conducted a tour of the physical plant with Administrator Raimonda. The following was noted: Facility is a single-story residence that consists of six (6) resident bedrooms and two (2) bathrooms. The LPA observed (1) fully charged fire extinguisher that was purchased on March 04, 2024. All smoke alarms and carbon monoxide detectors were tested and functioned properly during time of visit. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly. Kitchen: The kitchen appeared clean and the appliances and fixtures functional. The LPA observed a sufficient amount of perishable and non-perishable food at the facility; Sharp objects are stored in a locked closet. Bedrooms: The resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Bathrooms: LPA observed all bathrooms clean, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats in all bathrooms. Residents have sufficient amounts of supplies for personal hygiene. At 02:14 p.m. water temperature in resident’s restroom was measured at 110.4 degrees Fahrenheit. Report will continue on LIC809-C.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CRESTWOOD VILLA II	FACILITY NUMBER: 565801074
	VISIT DATE: 03/21/2024

NARRATIVE

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Common Areas: These included the living rooms and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. The facility maintained a comfortable temperature of 72 degrees.

Garage: The garage is where the washer and dryer are held. Cleaning supplies and disinfectants are kept in the garage. The garage is locked.

Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises.

Medication audit: Medications review began at 02:25 p.m. The LPA conducted medication audit for three (3) of six (6) residents. Medications are centrally stored and locked in a closet; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record.

Interviews: The LPA conducted one (1) resident interview and attempted to interview a second resident. No immediate concerns voiced during the visit.

File review: At 02:56 p.m. a review of facility files was initiated. The LPA reviewed two (2) of six (6) resident files. Out of the two files reviewed, the LPA identified that one resident (R1) requires an updated physician’s report, due to the diagnosis of dementia.

Due to time constraints the LPA will return to complete the annual at a later date.
Exit interview conducted and copy of the report and appeal rights provided to Administrator.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

LIC809 (FAS) - (06/04)

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