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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802444
Report Date: 07/30/2024
Date Signed: 07/30/2024 01:24:51 PM


Document Has Been Signed on 07/30/2024 01:24 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:LAND OF ENCHANTMENT 1 BOARD AND CARE LLCFACILITY NUMBER:
565802444
ADMINISTRATOR:ROXANA LARAFACILITY TYPE:
740
ADDRESS:78 W GAINSBOROUGH RDTELEPHONE:
(805) 601-5202
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 5DATE:
07/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Roxana LaraTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:14 AM. LPA was greeted by Facility staff who contacted the facility administrator Roxana Lara. Facility administrator arrived to the facility at approximately 09:20 AM Entrance interview conducted.

Beginning at 09:22 AM, the LPA, along with facility administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

COMMON AREAS: This includes the living room and dining room areas. LPA observed common area to be clean and properly furnished at the time of the visit. Cameras that do not record audio were observed in the common areas. A properly screened fireplace was noted in the living room. The LPA observed the fire extinguisher to be fully charged and purchased on 04/24/2024. Smoke detectors and carbon monoxide detectors were tested at 10:53 AM and were functional at the time of the visit.

KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) days perishable and two (2) days non-perishable food and emergency water. The LPA observed one designated cabinet where knives and sharps are stored locked and inaccessible to residents.

GARAGE: The entry to the garage was observed to be locked and inaccessible to residents. The garage was observed to contain a washer and dryer, laundry supplies and chemicals are stored in in the garage along with various cleaning supplies. Garage contained adequate emergency food and water supplies.
Report Continued on LIC 809-C
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024
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 07/30/2024 01:24 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: LAND OF ENCHANTMENT 1 BOARD AND CARE LLC
FACILITY NUMBER: 565802444

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(3)(A)
Personal Accommodations and Services
(A) A bed for each resident, except that married couples may be provided with one appropriate sized bed. Each bed shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. Fillings and covers for mattresses and pillows shall be flame retardant. Rubber sheeting shall be provided when necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as one resident does not have a bed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/06/2024
Plan of Correction
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Licensee will contact CCL to obtain a waiver to retain a resident without a bed. Licensee will submit letters describing the situation and the wishes of the resident. Letters are to be written and signed by the licensee, the resident, and the resident's responsible party. Licensee will submit the required documents to CCL no later than POC due date.
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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/30/2024 01:24 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: LAND OF ENCHANTMENT 1 BOARD AND CARE LLC
FACILITY NUMBER: 565802444

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(h)
(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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as two (2) out of two (2) exit gates failed to self latch which poses a potential health or safety risk to persons in care.
POC Due Date: 08/06/2024
Plan of Correction
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Licensee will contact an appropriate professional to perform the required work to ensure both gates self latch. Licensee will submit either of the following to CCL no later than the POC due date: a copy of the repair quote and an estimated date of completion or proof of work performed and evidence of gates properly self latching.
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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024
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: LAND OF ENCHANTMENT 1 BOARD AND CARE LLC
FACILITY NUMBER: 565802444
VISIT DATE: 07/30/2024
NARRATIVE
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Continued from LIC 809-C

BATHROOMS: There are three (3) bathrooms for resident use. Bathrooms were observed to be equipped with nonskid surfaces and contain nonskid mats. Grab bars were observed next to all toilets and in all showers and all were properly secured. The water temperature was measured between 105.8 and 109.8 degrees Fahrenheit, which is in compliance with regulation.

BEDROOMS: There are seven (7) bedrooms in the facility; six (6) are designated for resident use and one (1) is designated as a staff room. One (1) resident room was observed to lack a bed for the resident’s use. However, interviews with resident 1 (R1) confirmed that this was at their request and that they preferred to sleep in a recliner. All other resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.



OUTDOOR SPACE: The backyard has sufficient patio furniture including shaded tables and chairs for resident use. One outdoor shed was observed to contain extra care supplies. Facility has two exit gates that were observed to fail to self-latch, LPA observed clear passageways for emergency exit use.

RECORD REVIEW: At 10:26 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. No deficiencies were observed during records review.

MEDICATION REVIEW: Medications for 2 (two) of five (5) residents were observed. All medications reviewed were documented properly on their centrally stored medication and destruction record sheet and no deficiencies were observed during medication review.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the
facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Last emergency disaster drill was conducted 05/30/2024. The facility’s emergency disaster plan is up to date and adequate.

Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
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: LAND OF ENCHANTMENT 1 BOARD AND CARE LLC
FACILITY NUMBER: 565802444
VISIT DATE: 07/30/2024
NARRATIVE
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Continued from LIC 809-C

INTERVIEWS: LPA interviewed two (2) staff and three (3) residents. All residents were happy with the food and activities offered. All residents stated that staff treat them well and are attentive to their needs. Both staff were knowledgeable on resident rights, the different forms of abuse, and their roles and responsibilities.

During today’s visit LPA obtained a copy of the facility’s updated LIC500 and liability insurance.

Due to a previous obligation administrator Roxana Lara had to leave the facility before a copy of the report was issued. Administrator has designated manager assistant Markdel Estrada to receive and sign the report in their absence.

The following deficiencies were observed (See LIC 809-Ds) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Licensee was advised that failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC809 (FAS) - (06/04)
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