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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850150
Report Date: 09/16/2024
Date Signed: 09/16/2024 05:05:05 PM


Document Has Been Signed on 09/16/2024 05:05 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:VARENITA OF WESTLAKEFACILITY NUMBER:
565850150
ADMINISTRATOR:HANNAH MYERSFACILITY TYPE:
740
ADDRESS:95 DUSENBERG DRIVETELEPHONE:
(805) 413-3300
CITY:WESTLAKESTATE: CAZIP CODE:
91362
CAPACITY:115CENSUS: 90DATE:
09/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:57 AM
MET WITH:Mehrnoush "Mimi" GhorbankhaniTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Angela Barutyan and Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 09:57AM. LPAs met with staff and Wellness Manager (WM) Mehrnoush “Mimi” Ghorbankhani. Entrance interview conducted.

Beginning at 10:20AM, the LPAs, along with the WM 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:

LPAs observed fire extinguishers on every floor which were fully charged and last serviced 09/12/2024. Fire alarm devices are tested annually and were last tested 07/08/2024. Delayed egress door in the memory care unit was tested at 11:28AM and was functional at the time of the visit.

COMMON SPACES/AMENITIES: Common areas include the dining area, theater, gym, salon, physical therapy room, the Bistro, game room, arts and crafts room, a small outdoor courtyard, and a Wellness Center. Several common living spaces were observed throughout the facility. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted in the hallways. The emergency telephone numbers are posted in the entryway. Other required postings are posted on the first floor near the elevator. LPAs observed the Ombudsman Poster and DSS Complaint Poster throughout the community. LPAs observed pull cords readily available in the resident's restrooms and observed residents to be wearing signal pendants.

BEDROOMS: LPAs observed a random selection of nine (9) bedrooms at the facility of which two (2) were on the first floor, three (3) were on the second floor, and three (3) were in the memory care unit. All bedrooms were furnished appropriately with clean linens, furnishings, and sufficient lighting.

Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angela BarutyanTELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2024
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 09/16/2024 05:05 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: VARENITA OF WESTLAKE
FACILITY NUMBER: 565850150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that two (2) staff members did not have a transfer of criminal record clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2024
Plan of Correction
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One (1) out of two (2) staff was associated to the facility during the time of the visit. Administrator ensures that the remaining staff member will not be working at the facility and is taken off the schedule for the week until they are associated. Administrator will submit proof of livescan to CCL.
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: Angela BarutyanTELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/16/2024 05:05 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: VARENITA OF WESTLAKE
FACILITY NUMBER: 565850150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that six (6) of six (6) staff were missing 40 hours initial and 20 hours annual training which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 09/23/2024
Plan of Correction
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Administrator will ensure that initial and annual training will be started by next week for all staff. Administrator will submit proof of training plan to CCL by 09/23/2024.

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: Angela BarutyanTELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/16/2024 05:05 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: VARENITA OF WESTLAKE
FACILITY NUMBER: 565850150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that three (3) out of six (6) staff did not have First Aid training which poses a potential health and safety rights risk to persons in care.
POC Due Date: 09/27/2024
Plan of Correction
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Administrator agrees to have staff complete First Aid training and submit proof of completion to CCL by 09/27/2024.
Type B
Section Cited
CCR
87705(f)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:

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 in that cleaning solutions and scissors were stored accessible to residents with dementia which poses a potential health and safety risk to persons in care.
POC Due Date: 09/23/2024
Plan of Correction
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WM Ghorbankhani and Maintenance Director (MD) Michael Cornejo locked the kitchen area during the time of the visit. MD plans to replace the door to the kitchen area. Administrator will ensure that drawers and cabinets containing cleaning solutions and sharps will remain locked and inaccessible to residents. Administrator will submit a statement of understanding of the section cited above to CCL by 09/23/2024.
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: Angela BarutyanTELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2024
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: VARENITA OF WESTLAKE
FACILITY NUMBER: 565850150
VISIT DATE: 09/16/2024
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RESTROOMS: LPAs observed resident restrooms to be equipped with grab bars near the toilet and shower/tub, non-skid surfaces in the shower/tub, and pull cords. LPAs tested water temperatures in resident bathrooms and were measured to be between 105.4 and 110.7 degrees Fahrenheit, which is within the required range.

KITCHEN: At 11:30AM, LPAs toured the kitchen in the memory care unit. At 11:32AM, LPAs observed the cabinet under the sink to be unlocked and containing cleaning chemicals and solutions as well as the drawer next to the sink to be unlocked and containing a pair of scissors. WM Ghorbankhani and Maintenance Director Michael Cornejo locked the kitchen area during the time of the visit. LPAs toured the main kitchen at 12:30PM. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food as well as an emergency food and water supply.

MEDICATION REVIEW: At 10:53AM, LPAs reviewed medications for two (2) residents in the memory care unit and at 11:42AM, LPAs reviewed medications for two (2) residents in the assisted living unit. All medications reviewed were stored and documented per regulation.



RECORD REVIEW: Beginning at 01:09PM, LPAs reviewed six (6) staff and five (5) residents files for documents including but not limited to: resident Admission Agreement, TB test, health screening, staff training and fingerprint clearance. Six (6) out of 6 (six) staff files observed were missing 40 hours initial and 20 hours annual training and three (3) out of six (6) staff files were missing First Aid training. All five (5) resident files reviewed were in compliance with regulation at the time of the visit.
INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPAs reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted quarterly as is required, with the last drill conducted on 09/12/2024.
INTERVIEWS: During today’s visit, LPAs interviewed five (5) residents and four (4) staff.
During today's visit, LPAs obtained a copy of the facility's liability insurance.

Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Civil penalties were issued in the amount of $1000. Administrator was informed that failure to correct deficiencies may result in additional civil penalties.

Exit interview conducted, report issued, and appeal rights provided.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angela BarutyanTELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024
LIC809 (FAS) - (06/04)
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