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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802411
Report Date: 12/01/2022
Date Signed: 12/01/2022 11:33:58 AM


Document Has Been Signed on 12/01/2022 11:33 AM - 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:
12/01/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jennifer ShafferTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced Case Management – Other inspection at the facility due to a Civil Penalty not being assessed during complaint investigation control number 29-AS-20220104110534. The LPA met with Administrator Jennifer Shaffer. Entrance interview conducted.

It was revealed during the course of the investigation, that although Resident #1 (R1) had three (3) pressure injuries when admitted to the facility. R1 developed additional pressure injuries while in care. On 6/24/2022, LPA Arroyo substantiated allegation: resident developed pressure injuries while in care as R1 was reassessed after 90 days of being admitted to the above facility and was noted to have new wounds which included one (1) unstageable pressure injury on the right malleolus and two (2) stage 3 pressure injuries on the right hip and on the right buttock. Additionally, facility was cited on a separate case management-deficiencies on 6/24/2022 for admitting and retaining R1 in the facility with a stage 3 or higher pressure injury without being on hospice and there were no records indicating that an exception request was submitted in order for R1 to be admitted or to remain at the facility.

Civil penalties in the amount of $500 is being assessed today for citation previously issued on 6/24/2022 for deficiency 87615(a)(1) – Prohibited Health Conditions.

Due to a glitch in the system, the LIC 421IM for the immediate $500 civil penalty was unable to be assessed through citation previously issued on 6/24/2022 and therefore, will be issued manually.

Exit interview. Appeal Rights discussed. Copy of the report provided 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: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2022
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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