565801912-6-14-2024-29-AS-VCOY-D68U3W-20240614151412

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801912
Report Date: 06/14/2024
Date Signed: 06/14/2024 03:14:25 PM

Document Has Been Signed on 06/14/2024 03:14 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:	MCFADDEN ASSISTED LIVING		FACILITY NUMBER:	565801912
ADMINISTRATOR:	OPHELIA MCFADDEN		FACILITY TYPE:	740
ADDRESS:	1531 DWIGHT AVENUE		TELEPHONE:	(805) 419-6617
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	6	CENSUS: 6	DATE:	06/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:56 AM
MET WITH:	Ophelia Mcfadden		TIME COMPLETED:	03:45 PM

NARRATIVE

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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 8:55 a.m. LPA initially met with staff Julius Pamplona. Administrator Ophelia McFadden was contacted and arrived shortly at 9:06 a.m. Entrance interview conducted.

The LPA, along with Administrator and the assistant administrator, Nikky Puga toured 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.

The following was observed:

BEDROOMS: The facility consists of a total of five (5) bedrooms; four (4) designated for residents and one (1) designated for staff. Bedrooms #1 and #3 are designated for single use and bedrooms #2 and #4 are designated for double occupancy. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. During today visit, LPA observed staff room (room #5) be converted into a single use resident room. However, #5 does not have the appropriate fire clearance to retain any residents. LPA discussed that the facility needs to submit a new sketch along with the LIC200 and obtain appropriate fire clearance or move the resident back to a room with the appropriate clearance.

Continued on LIC809-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

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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Document Has Been Signed on 06/14/2024 03:14 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: MCFADDEN ASSISTED LIVING	FACILITY NUMBER: 565801912
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87307(d)(6)

Personal Accommodations and Services

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on bservation, the licensee did not comply with the section cited above. Exit # 2 by the dinning room to be blocked by a bed which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/13/2024
	Plan of Correction
1 2 3 4	Administrator removed bed from space between exit #2 and dinning room. LPA accepted correction.

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

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: MCFADDEN ASSISTED LIVING	FACILITY NUMBER: 565801912
	VISIT DATE: 06/14/2024

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Continued from LIC809

RESTROOMS: The LPA observed two (2) restrooms in the facility; one (1) is a shared restroom, and one (1) is a private restroom. Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperature was measured in the shared resident restroom at 9:43 a.m. and measured at 114.3 degrees Fahrenheit, which is within the required range.

COMMON SPACES: The common areas were checked for cleanliness. At the time of the visit, living room and dining room furniture was observed to be in good condition. At 9:35 am, LPA observed exit # 2 by the dinning room to be blocked by a bed. Per administrator, they recently added a door to make it a rest area for staff. LPA explained that the exit cannot be blocked due to fire clearance concerns. Additionally, LPA discussed any modifications made to the facility should be submitted to the department and requires permits prior to any modifications are completed. The LPA observed the required postings in the common area. A fireplace was observed to be adequately screened. Fire extinguishers were observed to be fully charged and last serviced during today’s visit. Carbon Monoxide detector was tested at 9:54 a.m., smoke detector was tested at 9:56 a.m. and both were functional at the time of the visit.

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. At 9:11 a.m. hot water temperature measured 116.9 degrees Fahrenheit.

OUTDOOR SPACE: The front yard is free of obstructions, the side gate at the front yard has a self-latching door. There is a yard area at the front of the house. LPA also observed a patio in the back yard which had shade and seating areas for residents to enjoy. There were no bodies of water noted.

Continued on LIC809C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

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: MCFADDEN ASSISTED LIVING	FACILITY NUMBER: 565801912
	VISIT DATE: 06/14/2024

NARRATIVE

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Continued from LIC809C

GARAGE: The garage was observed locked. LPA observed extra non-perishable food, and a refrigerator with extra food. Furthermore, laundry area, as well as emergency food supply and water, and storage space was observed in the garage. All cleaning compounds were stored in areas separately from food supplies. Additionally, at 9:14 am, LPA observed several garage storage cabinets with clothes and two (2) chests of drawers full of clothes along with a twin bed in the garage. Interviews with the administrator/assistant administrator reflected that staff sometimes sleep in the garage or rest there between shifts. During the visit, Licensing Program Manager (LPM) Desaree Perera spoke with administrator and discussed that upon licensure facility did consists of a staff room and had live in staff. However, based on observation and interviews, resident requested for a private room therefore, the designated staff room was converted into resident room and staff were moved to the garage. Administrator agreed to remove all beds and any furniture from the garage and submit proof to licensing.

LPM, LPA and administrator also held a discussion that if the facility chooses not to have a designated staff room, the facility is required to have 24/7 awake night staff and that staff cannot use common areas nor the garage to sleep. A review of the current LIC 500 reflected staff only 7:00 a.m. – 7:00 p.m., LPA requested an updated LIC500 and addendum to the plan of operation to be submitted if the facility wish to no longer have a designated staff room. LPA received updated LIC 500 from Administrator during today's visit.

INTERVIEWS: Beginning at 11:00 am, LPA interviewed 2 (two) staff and 2 (two) residents. No concerns at the time of the visit.

Continiued from LIC809C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

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: MCFADDEN ASSISTED LIVING	FACILITY NUMBER: 565801912
	VISIT DATE: 06/14/2024

NARRATIVE

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Continued from LIC809C\

RECORD REVIEW: Began at 11:20 am, staff and resident records were reviewed for documents including, but not limited to, health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. Six (6) resident records reviewed were complete and contained all required documents. Record reviewed that one (1) resident is in hospice and suffers of dementia, two (2) residents are receiving home health. No residents using oxygen currently. Four (4) staff files reviewed were complete and contained all required documents. The facility’s policies and procedures as it pertains to infection control are adequate. Last drill was conducted on 03/05/2024 LPA reminded administrator back up that drills shall be conducted quarterly.

MEDICATION REVIEW: Began at 12:15 pm. Medications for six (6) residents were observed. All six (6) of six (6) residents' prescription medications were observed to be maintained and administered in compliance with regulation.

Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D).

Exit interview conducted, Citations/civil penalties issued /A copy of the report and appeal rights were issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/14/2024 03:14 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: MCFADDEN ASSISTED LIVING	FACILITY NUMBER: 565801912
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interviews and record review, the licensee did not comply with the section cited above , 1 out of 6 non-ambulatory resident is admitted in room #5 which is fire cleared as a staff room, which poses an immediate safety risk to persons in care. Violating Section 87204(b) Resident rooms...shall not accommodate nonambulatory residents. Residents...nonambulatory shall not remain in rooms restricted to ambulatory residents
	POC Due Date: 06/18/2024
	Plan of Correction
1 2 3 4	LPA is requesting fire clearance for room #5. Administrator is in communication with Sr. Rod Torres.

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

LIC809 (FAS) - (06/04)

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