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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801930
Report Date: 07/07/2021
Date Signed: 07/07/2021 07:55:43 PM

COMPREHENSIVE INSPECTION
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:NAVITA RESIDENCE YOUNG AVEFACILITY NUMBER:
565801930
ADMINISTRATOR:PRESEEDHA ANDICOTFACILITY TYPE:
740
ADDRESS:2024 YOUNG AVETELEPHONE:
(805) 413-2129
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 6DATE:
07/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Praveen Syamala, Licensee RepresentativeTIME COMPLETED:
07:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Martha Guzman Chavez and JoAnn Rosales arrived at the facility unannounced at 10:30 am for a 1-year annual inspection. LPAs were greeted at the door by caregiver Leonard Merca and Karthiga Vijayakumar. Licensee Representative Praveen Syamala arrived at the facility at 10:55am.

Between 10:36am and 11:20am, LPAs began the physical plant tour with staff Leonard Merca of the common areas, laundry room, kitchen area, resident bedrooms, staff room, bathrooms, and outdoor area to ensure facility is in compliance with Title 22 Regulations. During this time, LPAs observed no emergency exit plans being posted throughout the facility.

Between 11:25am – 3:30pm, LPAs reviewed resident records, staff records, medications and medication records.

During the medications review with Staff Merca, discrepancies were found in Residents #1 (R1) and R2 medications storage and prescription labels. At 1:13pm, LPAs observed R1 medication, Calcitonin Salmon Nasal Spray not properly stored as it was stored in the refrigerator, however, instructions on the medication indicate to be stored in room temperature after opening. Also, it did not have a prescription label as the medication box had been discarded. This medication had been opened and was currently being given to R1. At 1:29pm, LPAs observed R2 medication Latanoprost Ophthalmic Solution and Dorzolaminade HCI Timolol Maleate Ophthalmic Solution to not have a prescription label as the medication box was discarded.

LPA Rosales spoke with Licensee Representative on 7/6/21 starting at 10:42 am regarding the suspended Kidilams Corporation. Licensee Representative stated that they have contacted the Franchise Tax Board Representative

Continued on LIC809c

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-ChavezTELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 9
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: NAVITA RESIDENCE YOUNG AVE
FACILITY NUMBER: 565801930
VISIT DATE: 07/07/2021
NARRATIVE
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Continued from LIC 809

they have indicated that the Corporation can continue to do business. Licensee Representative stated that they have submitted the requested documents to the Franchise Tax Board to reflect no pending tax payments and it will take approximately 6 weeks to process. Licensee Representative stated that the Corporation has been suspended since October 2020. Licensee Representative stated that they did not have knowledge of the suspension until LPA notified them of the suspension on 6/30/2021.

OUTDOOR SPACE: The LPAs observed the backyard to have a covered outdoor area with a table and chairs for resident use. At 11:06am, LPAs observed one of the perimeter fence gates locked with a dial lock and not self-closing. LPAs observed outdoor ramps without a handrail which were accessible to residents on the outside pathways. One of the ramps was observed blocking one of the perimeter fence gates from opening.

KITCHEN: The LPAs observed the kitchen/dining area to be clean. At 10:42 am, LPAs observed dish soap, which was on the counter above the kitchen sink accessible to residents. At 10:44am, LPAs observed the knives to be stored in a locked cabinet in the kitchen island, except for one (1) knife that was observed in the kitchen sink accessible to residents. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

LAUNDRY ROOM: At 10:38am LPAs observed laundry room to have an unlocked cabinet with Lysol spray, febreeze, disinfecting wipes, toilet cleaner, pine sol, dryer sheets, and laundry softener accessible to residents. At 10:40am, LPAs observed detergent in the laundry room on the floor accessible to residents.

BEDROOMS: The LPAs observed 5 out of the 6 resident bedrooms to be furnished appropriately. Observed inside each room was a bed with clean linens, a nightstand, and a table lamp. At 10:37am, LPAs observed R4 with door open and accessible to other residents were toothpaste and shaving cream. At 10:59am, LPAs observed R2 with two (2) couches and no bed. At 11:01am, LPAs observed R2 to have a bed with half bed rail and no Physicians order on file.

Continued on LIC 809c

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-ChavezTELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
LIC809 (FAS) - (06/04)
Page: 2 of 9
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: NAVITA RESIDENCE YOUNG AVE
FACILITY NUMBER: 565801930
VISIT DATE: 07/07/2021
NARRATIVE
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Continued from LIC 809c

RESTROOMS: LPAs observed the restrooms to be clean, sanitary and in operating condition with grab bars and non-skid mats inside the shower. At 10:39am, LPAs observed bathroom #1 to have febreeze, toilet cleaner, body cream, toothpaste, disinfecting wipes, body wash, shampoo, and conditioner accessible to residents. Bathroom #2 water temperature was checked and in compliance at 105.9 degrees Fahrenheit.

LPAs observed the binder for Disaster Drills to reflect trainings are being conducted quarterly. Last disaster drill training conducted on 6-29-2021. LPAs reviewed First Aid kit which was complete.

Licensee Representative had to leave facility during the visit, LPAs met with Staff Vijayakumar who is authorized to review and sign reports.

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, today's reports and appeal rights were reviewed with Staff Vijayakumar and emailed to the Administrator.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-ChavezTELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
LIC809 (FAS) - (06/04)
Page: 3 of 9
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: NAVITA RESIDENCE YOUNG AVE
FACILITY NUMBER: 565801930
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/08/2021
Section Cited

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2
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7
87465 Incidental Medical and Dental Care (h)(4) All centrally stored medication shall be labeled and maintained in compliance with the federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
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9
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Based on record review, the licensee did not comply with the section cited above in 2 of 6 resident records as R1's calcitonin salmon was not labeled and properly stored and R2's eye drops were not labeled which poses an immediate health risk to persons in care.
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Type A
07/08/2021
Section Cited

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87705 Care of Persons with Dementia (l)(2)The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates.

This requirement is not met as evidenced by:
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Based on LPAs observation, the licensee did not comply with the section cited above as one of the outside perimeter fence gate was locked which poses an immediate safety risk to persons in care.
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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 PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-ChavezTELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2021
LIC809 (FAS) - (06/04)
Page: 4 of 9
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: NAVITA RESIDENCE YOUNG AVE
FACILITY NUMBER: 565801930
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/08/2021
Section Cited

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2
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87705 Care of Persons with Dementia (f)(1) The following shall be stored inaccessible to residents with dementia:Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
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14
Based on LPA’s observations, the licensee did not comply with the section cited above as a knife was observed accessible to residents which poses an immediate safety risk to persons in care.
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Type A
07/08/2021
Section Cited

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87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: 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:
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Based on LPA’s observations, the licensee did not comply with the section cited above as toxic items were observed in an accessible location to residents which posed an immediate health risk to persons in care.
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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 PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-ChavezTELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2021
LIC809 (FAS) - (06/04)
Page: 5 of 9
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: NAVITA RESIDENCE YOUNG AVE
FACILITY NUMBER: 565801930
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/07/2021
Section Cited

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87205 Accountability of Licensee Governing Body (b) If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability.


This requirement is not met as evidenced by:
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Based on interviews, the licensee did not comply with the section cited above as the facilities corporation has been suspended with the CA Secretary of State since October 2020 which poses a immediate personal rights risk to persons in care.
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Type B
07/14/2021
Section Cited

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87307 Incidental Medical and Dental Care (a)(3)(A) A bed for each resident, except that married couples... Each bed shall be equipped with good springs, a clean and comfortable mattress... Fillings and covers for mattresses...Rubber sheeting shall be provided when necessary.
This requirement is not met as evidenced by:
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Based on LPAs observations, the licensee did not comply with the section cited above as R3 did not have a bed in their bedroom which poses a potential health and personal rights risk to persons in care.
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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 PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-ChavezTELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2021
LIC809 (FAS) - (06/04)
Page: 6 of 9
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: NAVITA RESIDENCE YOUNG AVE
FACILITY NUMBER: 565801930
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/14/2021
Section Cited

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87608 Postural Support. (a)(5)(A) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.
This requirement is not met as evidenced by:
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Based on LPAs observation, the licensee did not comply with the section cited above as they did not have a physicians order for R2's half bedrail which poses a potential safety risk to persons in care.
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Type B
07/14/2021
Section Cited

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87705 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:
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Based on LPAs observations, the licensee did not comply with the section cited above as one of the outside perimeter gates was not self-closing which poses a potential safety risk to persons in care.
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14
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 PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-ChavezTELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2021
LIC809 (FAS) - (06/04)
Page: 7 of 9
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: NAVITA RESIDENCE YOUNG AVE
FACILITY NUMBER: 565801930
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/14/2021
Section Cited

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7
87307 Personal Accommodations and Services (d)(4). Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted.
This requirement is not met as evidenced by:
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Based on LPAs observation, the licensee did not comply with the section cited above as the outdoor ramps were accesible to residents which poses a potential safety risk to persons in care.
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Type B
07/14/2021
Section Cited

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87307 Personal Accommodations and Services (d)(6)All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
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Based on LPAs observation, the licensee did not comply with the section cited above as one of the outside passageways was blocked by a ramp which poses a potential safety risk to persons in care
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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 PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-ChavezTELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2021
LIC809 (FAS) - (06/04)
Page: 8 of 9
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: NAVITA RESIDENCE YOUNG AVE
FACILITY NUMBER: 565801930
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/09/2021
Section Cited

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3
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6
7
87212 Emergency Disaster Plan (c) Emergency exiting plans and telephone numbers shall be posted.

This requirement is not met as evidenced by:
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14
Based on LPAs observation, the licensee did not comply with the section cited above as facility did not have emergency exiting plans posted which poses a potential safety risk to persons in care.
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14

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7

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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 PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-ChavezTELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2021
LIC809 (FAS) - (06/04)
Page: 9 of 9