565802461-8-5-2024-29-AS-BBAI-D7UTX5-20240805150634

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802461
Report Date: 08/05/2024
Date Signed: 08/05/2024 03:09:00 PM

Document Has Been Signed on 08/05/2024 03:09 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:	IVY PARK AT WOOD RANCH		FACILITY NUMBER:	565802461
ADMINISTRATOR:	EDITH KENNEDY		FACILITY TYPE:	740
ADDRESS:	190 TIERRA REJADA RD		TELEPHONE:	(805) 584-8881
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	100	CENSUS: 69	DATE:	08/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Lilit Mnatsakanyan - Executive Director		TIME COMPLETED:	03:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst's (LPAs) Brian Balisi and Martha Arroyo conducted a required annual to the above noted facility. Upon arrival, LPA's met with Executive Director Lilit Mnatsakanyan and explained the reason for the visit. LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. The facility is two-story. At 10:10am, a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for ninety-two (92) non-ambulatory residents; and eight (8) bedridden residents. The facility has a capacity total of one hundred (100) residents. The facility has an approved fire clearance for bedridden in any bedroom on both the first and second floors, front desk will maintain current roster of bedridden residents’ room location. There is one central kitchen that distributes food to the 3 dining rooms. The kitchen contained a walk-in pantry with a sufficient supply of canned foods, and emergency food and water. The walk-in refrigerator and freezer were observed to have an ample supply of perishable and nonperishable food supplies. The freezer was maintained at zero degrees Fahrenheit, and the refrigerator was maintained at 40 degrees Fahrenheit. The supply of dishes, utensils, pots, pans, and drink ware is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Cleaning supplies are stored separately from food preparation areas in locked storage closets throughout the facility. There are three (3) laundry rooms throughout the facility for resident use. No flies or other vermin were observed. The common areas were appropriately furnished, and the lighting was adequate. The common areas on the first floor consists of the bistro, 2 separate dining areas, a living room, movie room, and multiple activity rooms. Also, on the first floor were observed several offices, staff lounge, a copy room, and a supply room.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024

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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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: IVY PARK AT WOOD RANCH	FACILITY NUMBER: 565802461
	VISIT DATE: 08/05/2024

NARRATIVE

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The second-floor common areas consists of the beauty salon, dining room, leisure/lounge room, offices, and multiple other activity rooms. Smoke alarms, carbon monoxide detectors, sprinklers and fire extinguishers were observed throughout the facility. LPA obtained a copy of the most recent Sprinkler and smoke detector inspection conducted. The fire extinguishers were observed fully charged and last serviced 10/20/2023. The emergency exiting plans/sketch are posted throughout the hallways. The facility has required postings, including emergency exit plan, Licensing Complaint Poster, Resident Personal Rights, Theft and Loss Policy, and Resident Council Rights. There is a functioning telephone on the premises. Emergency evacuation chairs were present in all stairways. The facility has approved delayed egress systems in the Memory Care unit. There is a secured patio area with tables and chairs for residents within the Memory Care unit. There is also a large outdoor space with shaded areas and adequate furniture for resident use throughout the facility. All passageways, walkways, driveways, steps and patios are free from obstructions and hazards at this time.

All resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs, and closet space. The beds are furnished with box springs, comfortable mattress, and clean linen, which includes, a mattress pad, top and bottom linens, pillowcases, blanket, and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath, or toilet. All rooms were free of odors. All window screens were clean and maintained in good repair.

The resident bathrooms have a shower with non-skid surfaces. The toilet and shower have grab bars. The hot water temperature was tested in random resident rooms in the Assisted Living area and was found to be within the range of 105 degrees Fahrenheit and 120 degrees Fahrenheit. The hot water temperature was also tested in random resident rooms in the Memory Care area and was found to be within the range of 105 degrees Fahrenheit and 120 degrees Fahrenheit.

Resident and staff records are stored in the Business Director’s office. Medications are centrally stored in the Medications Room / Nurses Station which is located on the second floor.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: IVY PARK AT WOOD RANCH	FACILITY NUMBER: 565802461
	VISIT DATE: 08/05/2024

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In addition, there are total of four (4) medication carts located throughout the facility. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. They were stored in the medication room.

LPA’s reviewed Records at approx. 11:22 a.m. Six (6) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Personnel files were printed at the time of visit. Seven (7) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. Daily vehicle inspection list and California Highway Patrol Inspection report was reviewed for facility vehicles. All records were observed to be in order at this time.

Medications review began at 01:30pm, The medications are centrally stored in the medication room. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

Infection control: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene. The facility has an adequate supply of Personal Protection Equipment (PPE), and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of an infectious disease. The facility’s policies and procedures as it pertains to infection control are adequate.

LPAs conducted interviews during the visit. LPAs obtained the following documents - Census, Staff schedule, Emergency Disaster plan and updated Limited Liability insurance.

Exit interview conducted and copy of report issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024

LIC809 (FAS) - (06/04)

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