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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802411
Report Date: 06/24/2022
Date Signed: 06/24/2022 01:42:50 PM


Document Has Been Signed on 06/24/2022 01:42 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:ANITA'S CARE VILLAFACILITY NUMBER:
565802411
ADMINISTRATOR:SHAFFER, JENNIFERFACILITY TYPE:
740
ADDRESS:521 LOUIS DRIVETELEPHONE:
(805) 716-3633
CITY:NEWBURY PARKSTATE: CAZIP CODE:
91320
CAPACITY:6CENSUS: 3DATE:
06/24/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Jennifer ShafferTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced Case Management - Deficiencies inspection at the facility due to a deficiency observed during complaint investigation control number 29-AS-20220104110534. The LPA met with Administrator Jennifer Shaffer. Entrance interview conducted.

Per record review, on 12/02/2021, Resident #1 (R1) was admitted to the facility with a Stage 3 pressure injury on the left heel, with measurements of 2cm x 3cm x 0.2cm; and a Stage 2 pressure injury on right lateral malleolus, with measurement of 1cm x 1cm x 0.2cm. Still, R1 was admitted to and retained in this facility with a Stage 3 or higher without being on hospice. Furthermore, Medical Records obtained and reviewed from 1/03/2021 indicated R1 had an Unstageable pressure injury on the right lateral malleolus, with measurements of 3.5cm x 2.5cm x 0.5cm; a Stage 3 pressure injury on the right hip, with measurements of 0.75cm x 1.75cm x 0.2cm; and a Stage 3 pressure injury on the right buttock, with measurements of 1.5cm x 1.5cm x 0cm. Additionally, a stage 3 and unstageable pressure injuries are considered a Prohibited Health Condition. There were no records indicating that an exception request was submitted in order for R1 to be admitted or to remain at the facility.

Per California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited.

Exit interview. Appeal Rights discussed. Copy of the report sent to the Administrator via email.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2022
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 2


Document Has Been Signed on 06/24/2022 01:42 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: ANITA'S CARE VILLA
FACILITY NUMBER: 565802411

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/25/2022
Section Cited

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87615(a)(1) Prohibited Health Conditions. (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained...: (1) Stage 3 and 4 pressure injuries.
This requirement is not met as evidenced by:
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Based on interview and records review, the licensee did not comply with the section cited above, as they admitted and retained R1 in the facility with a prohibited health condition, which poses an immediate health and safety risk to residents 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 ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2022
LIC809 (FAS) - (06/04)
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