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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802426
Report Date: 08/04/2022
Date Signed: 08/04/2022 02:34:51 PM


Document Has Been Signed on 08/04/2022 02:34 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:NAVITA RESIDENCE TULL STFACILITY NUMBER:
565802426
ADMINISTRATOR:PRAVEEN SYAMALAFACILITY TYPE:
740
ADDRESS:5603 TULL STTELEPHONE:
8054944121
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:6CENSUS: 6DATE:
08/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Karthiga VijayakumarTIME COMPLETED:
01:56 PM
NARRATIVE
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Licensing Program Analyst (LPA) JoAnn Rosales conducted a Required 1 - Year visit to this facility. LPA met with staff Karthiga Vijayakumar. Staff Vijayakumar is authorized to review and sign reports.

LPA conducted a facility tour to inspect for infection control practices. Infection control practices were discussed with Staff Vijayakumar. An inspection of the common areas, resident rooms and restrooms were conducted. LPA observed hot water temperature at 107.6 degrees F. in resident bathroom. There is an adequate amount of perishable and non-perishable food. PPE supplies were observed. First Aid kit is complete. LPA observed the fire extinguisher fully charged. The smoke detectors and carbon monoxide detectors were tested and operable. Centrally stored medicines are kept in a locked kitchen cabinet. Hygiene items are being provided. Grab bars and non-skid materials were present in the bathrooms. LPA reviewed a sampling of resident records and medications. LPA reviewed a sampling of staff records.

During a review of resident records with staff Vijayakumar starting at 11:43 am LPA observed that resident #1 (R1) does not have a current physicians report and reappraisal on file and R3 does not have a current physicians report on file.

During a review of resident medications with staff #1 (S1) and staff Vijayakumar starting at 12:25 pm LPA observed that R1 does not have a physicians order for melatonin 3 mg, R2 does not have a physicians order for aspirin 81 mg, multivitamins, caltrate bone health 600 + D3 and R3 does not have a physicians order for iron 65 mg.

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 and emailed to the Administrator.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
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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Document Has Been Signed on 08/04/2022 02:34 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: NAVITA RESIDENCE TULL ST
FACILITY NUMBER: 565802426

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations and record review, the licensee did not comply with the section cited above in 3 out of 3 resident medications which poses an immediate health risk to persons in care.
POC Due Date: 08/05/2022
Plan of Correction
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Staff stated they will not give residents medications without a a physicians order on file. Staff stated they will provide documentation medication training regarding regulation 87465(e) to CCL by 8/15/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 08/04/2022 02:34 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: NAVITA RESIDENCE TULL ST
FACILITY NUMBER: 565802426

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and record review, the licensee did not comply with the section cited above in 2 out of 3 residents which poses a potential health and safety risk to persons in care.
POC Due Date: 08/15/2022
Plan of Correction
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Staff stated that they will provide documentation of R1's current physicians report and reappraisal and R3's current physicians report to CCL by 8/15/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
LIC809 (FAS) - (06/04)
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