565850150-9-12-2023-29-AS-DCHZ-CVM396-20230912180238

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850150
Report Date: 09/12/2023
Date Signed: 09/12/2023 06:03:02 PM

Document Has Been Signed on 09/12/2023 06:03 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:	VARENITA OF WESTLAKE		FACILITY NUMBER:	565850150
ADMINISTRATOR:	VEJAR, MERI		FACILITY TYPE:	740
ADDRESS:	95 DUSENBERG DRIVE		TELEPHONE:	(805) 413-3300
CITY:	WESTLAKE	STATE: CA	ZIP CODE:	91362
CAPACITY:	90	CENSUS: 37	DATE:	09/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Brad Stewart, Administrator/Executive Director		TIME COMPLETED:	06:20 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	On 9/12/23 at 10:40 am, Licensing Program Analysts (LPAs) Darlene Chavez and Kelly Dulek made an unannounced Annual/Required visit to the facility listed above. LPA met with Brad Stewart, Executive Director. Hannah Myers, Administrator, was on-site during the visit. A tour of the physical plant was assessed, and the following was noted: LPA Dulek observed the license posted, Complaint Poster, Bill of Rights and Right to Residential Council, non-discrimination statement, and resident rights in common areas throughout the facility. Physical plant was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, all in good condition. The facility maintains a comfortable temperature. The smoke detectors and carbon monoxide detectors are hard-wired. Fire extinguishers located throughout the facility were fully charged, however, last inspection was completed on 6/15/22. Licensee will have extinguishers inspected and send photos to LPA by 9/19/23. There are no issues with Fire Clearance. Living space furniture were checked and in good condition. The common rooms are clean, safe and sanitary. The courtyards of the facility have outdoor furniture with shaded area for residents. The kitchen is sufficiently stocked with two-day perishable and seven-day non-perishables. Foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Resident rooms are adequately dressed with sheets, pillowcase, mattress pad, and blankets which are in good condition. There is at least one chair, nightstand and sufficient lighting for each resident. There is enough linen available to change regularly. Storage has sufficient amounts of personal hygiene product which is provided by the licensee. Continued on 809-C.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

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 09/12/2023 06:03 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: VARENITA OF WESTLAKE	FACILITY NUMBER: 565850150
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interviews, the licensee did not comply with the section cited above in that One out of five staff files reviewed indicate staff do not have documentation showing negative TB tests which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/13/2023
	Plan of Correction
1 2 3 4	Licensee will provide TB results for staff without results to CCL or provide documentation showing the test is in process by the due date.

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: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

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: VARENITA OF WESTLAKE	FACILITY NUMBER: 565850150
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(1)(C)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (C) Because of potential dangers related to the medication itself, or due to physical arrangements in the facility and the condition or the habits of other persons in the facility, the medications are determined by either a physician, the administrator, or Department to be a safety hazard to others. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, record review and interviews, the licensee did not comply with the section cited above in medications were found in resident's room and resident's LIC 602 indicates resident cannot store/administer medications which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/13/2023
	Plan of Correction
1 2 3 4	Wellness DIrector immediately stored medications in the wellness office. Wellness DIrector will conduct training with staff on proper medication storage, send LPA an agreement to LPA by 9/13/23 that training will be finalized by 9/19/23. Agreement will include that training sign-in sheets will be sent to LPA by 9/19/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/12/2023 06:03 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: VARENITA OF WESTLAKE	FACILITY NUMBER: 565850150
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interviews, the licensee did not comply with the section cited above in five out of five staff files indicate staff did not complete annual required training which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/19/2023
	Plan of Correction
1 2 3 4	Licensee has agreed to ensure that staff complete annual training and send sign-in sheets to CCL by due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

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: VARENITA OF WESTLAKE	FACILITY NUMBER: 565850150
	VISIT DATE: 09/12/2023

NARRATIVE

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Bathrooms were checked for cleanliness and proper operation. Hot water temperatures measured were within regulation.
A sampling of medications show medications for one resident were stored in their room, and the physician report (LIC 602) indicates they cannot store nor administer their own medications. Deficiency cited. First Aid kit has all proper items and is current.
Resident records were reviewed for requirements and legibility: LPA reviewed 5 residents’ files for Medical Assessments, Needs and Service plans, Signed Admission Agreements and Pre-appraisals. All five residents need dentist information added to the Identification and Emergency Information Sheets. Technical violation issued. Planned activities are offered to residents in care.
Staff records. LPA conducted a file review of 5 staff for criminal record clearances/associations, current First Aid, and training. One out of five staff files reviewed indicate staff do not have documentation showing negative TB tests. Deficiency cited. One out of five staff files reviewed indicate staff was not associated with the facility. Deficiency cited, civil penalty issued. The first aid certification for all five staff is complete. Five out of five staff records reviewed indicate annual training was not completed. Deficiency cited. Quarterly emergency disaster drills have been completed.
Liability Insurance: LPA observed an email provided by Executive Director indicating the facility has liability insurance, however, it was not sent by the insurance company. Dates of coverage are 11/1/22 through 11/1/23 with required coverage amounts. Technical violation issued. Licensee will provide proof of liability insurance to LPA by 9/13/23.

Exit interview conducted, deficiencies cited, civil penalty given, technical violations issued, and the report and appeal rights given.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/12/2023 06:03 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: VARENITA OF WESTLAKE	FACILITY NUMBER: 565850150
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(2)

Request for a transfer of a criminal record clearance specified in Section 87355( c). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interviews, the licensee did not comply with the section cited above in that one out of five staff files reviewed indicate that staff was not associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/13/2023
	Plan of Correction
1 2 3 4	Licensee immediately associated staff to facility. No further action needed.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

LIC809 (FAS) - (06/04)

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