565801418-9-26-2023-29-AS-ECOZ-CW2V49-20230926160559

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801418
Report Date: 09/26/2023
Date Signed: 09/26/2023 04:07:16 PM

Document Has Been Signed on 09/26/2023 04:07 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:	GAINSBOROUGH OAKS		FACILITY NUMBER:	565801418
ADMINISTRATOR:	MARIA L. MACANDILI		FACILITY TYPE:	740
ADDRESS:	91 W. GAINSBOROUGH ROAD		TELEPHONE:	(805) 777-8802
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 2	DATE:	09/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Maria L. Macandili		TIME COMPLETED:	04:10 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	At 12:45 p.m. Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by staff Willfredo Macandili and informed them of the reason for the visit. Administrator Maria Macandili arrived shortly. At 01:12 p.m. the LPA conducted a tour of the physical plant with Administrator Maria to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a single-story residence that consists of three (3) resident, and three (3) staff bedrooms and two (2) bathrooms. The LPA observed a fire extinguisher which was fully charged and recently purchased on 09/22/2023. All smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed all required postings throughout the facility. Kitchen: During the facility tour at 1:15 p.m. 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 cabinet. 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: The LPA observed the resident bathroom, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats the bathroom. The hot water was measured in the resident communal bathroom during the physical plant tour. Hot water measured 124.3 degrees Fahrenheit at 1:18 p.m. Upon observation, staff attempted to lower the temperature, however the hot water was remeasured at 124.1 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: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

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 09/26/2023 04:07 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GAINSBOROUGH OAKS	FACILITY NUMBER: 565801418
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/26/2023

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 observation, the licensee did not comply with the section cited above in the residents bathroom as the hot water measure 124.3 degrees F which poses an immediate health and safety risk to persons in care.
	POC Due Date: 10/02/2023
	Plan of Correction
1 2 3 4	The Licensee agrees to adjust the thermostat and submit a hot water temperature log for five (5) to show that the hot water is being maintained between temperatures 105- and 120-degrees Fahrenheit.

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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GAINSBOROUGH OAKS	FACILITY NUMBER: 565801418
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in as staff #1 did not have any annual training which poses a potential health and safety risk to persons in care.
	POC Due Date: 10/10/2023
	Plan of Correction
1 2 3 4	Licensee agrees to submit proof of Staff #1 completed annual training by the POC due date.

Type B

Section Cited

CCR

87506(b)

Resident Records

(b) Each resident's record shall contain at least the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as both resident files were incomplete, missing their LIC602, LIC625 and R1 also had an incomplete pre-placement appraisal which poses a potential health and safety risk to persons in care.
	POC Due Date: 10/10/2023
	Plan of Correction
1 2 3 4	Licensee agrees to obtain all missing documents for R1 and R2 and submit proof to CCL by the POC due date.

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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/26/2023 04:07 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GAINSBOROUGH OAKS	FACILITY NUMBER: 565801418
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above as there was no quarterly emergencyh drill conducted which poses a potential health and safety risk to persons in care.
	POC Due Date: 10/10/2023
	Plan of Correction
1 2 3 4	Licensee agreed to conduct an emergency drill this month and submit proof to CCL by POC due date

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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GAINSBOROUGH OAKS	FACILITY NUMBER: 565801418
	VISIT DATE: 09/26/2023

NARRATIVE

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Common Areas: These included the living room 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 75 degrees. The LPA observed the fireplace in the living room adequately screened. There were no obstructions and/or tripping hazards throughout the facility. Cleaning supplies were stored in a locked cabinet inside the laundry room.

Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture and a swimming pool that was gated and locked. The garage was locked and attached the house.

Record Review: At 01:45 p.m. a review of facility files was initiated. The LPA reviewed two (2) out of two (2) Resident Files. The LPA identified that resident #1 is missing their Physicians report (LIC602), appraisal/needs and services plan (LIC 625), and their pre-placement appraisal was not filled out. Resident #2 is missing their LIC602, and LIC625. The LPA reviewed two (2) out of two (2) staff files and the following was noted: Both staff did not have a current first aid certification, and staff #1 (S1) did not have any annual training. Administrator Maria was not able to provide documentation of the updated emergency and disaster plan and stated that they have not conducted a quarterly disaster drill.

Medications: At 2:30 p.m. a medication review was initiated. Medications are centrally stored and locked in a cabinet in the kitchen; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

Interviews: At 2:45 p.m. the LPA conducted one (1) staff interview and attempted to interview two (2) residents.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided to Administrator Maria Macandili.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC809 (FAS) - (06/04)

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