565850150-9-2-2022-29-AS-ASMH-CHVSFT-20220902135050

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850150
Report Date: 09/02/2022
Date Signed: 09/02/2022 01:52:11 PM

Document Has Been Signed on 09/02/2022 01:52 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: 0	DATE:	09/02/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Meri Vejar		TIME COMPLETED:	02:00 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 (LPA) Ashley Smith arrived for a pre-licensing visit at 9:30 a.m. The LPA met with Executive Director Meri Vejar and explained the reason for the visit. This is a new facility. A dementia program was included in the plan of operation. Component III was conducted in conjunction with this pre-licensing visit. An approved fire clearance was received on 07/12/2022, clearing all rooms for non-ambulatory use. All bedrooms cleared for bedridden use; however, this facility shall be limited to a maximum capacity of eight (8) bedridden residents. Facility Layout: The facility layout includes a garden/subterranean level, the first floor, and the second floor. The garden-level amenities include the main kitchen and dining area, theater, gym, salon, and physical therapy room. It was observed that the salon was unfinished. The first floor includes the Bistro, several common living spaces, game room, arts and crafts room, and a small outdoor courtyard adjacent to the Bistro. The second floor has several common living spaces and a Wellness Center. The Wellness Center on the second floor required additional drywall. Rooms: The facility has eighty-six (86) units. The Memory Care Unit is located on the first floor. The resident rooms in the Memory Care Unit are single-room occupancy and have no appliances. Lighting in the rooms appeared adequate. There is a separate dining space for memory care residents, as well as several open common spaces and activity areas. Delayed egress was tested in the memory care unit and it was functional at the time of the visit. There is a separate outdoor courtyard for memory care residents with furniture for resident use. The rooms for assisted living residents are equipped with a refrigerator, microwave, and sink, and in-unit washer and dryer. 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. Rooms designated for assisted living residents are on the first and second floor.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022

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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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: 09/02/2022

NARRATIVE

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Twelve (12) rooms were randomly selected for inspection. During the physical plant tour, the following rooms required installation of window screens: Room #27, #234, #243.

Bathrooms: Bathrooms were equipped with grab bars near the toilet and shower/tub, and non-skid surfaces were observed in the shower/tub. During today's visit, water temperature was tested throughout the community, and ranged between 80 to 131.8 degrees Fahrenheit. However, the community is going to ensure that water is tested within range upon repairs.

Medications: Medications will be stored in the Wellness Center on the second floor. There is a complete first-aid kit and a surplus of supplies. There are additional first aid kits throughout the community. There are medication carts with double locking system for narcotics for both assisted living and memory care residents.

Common Spaces: Regarding the pendant system, the system is activated in the resident restrooms and common restrooms. There is no alarm or pull cord readily available in the resident's 'bedroom' at this time. All systems go directly to a computer at the front desk and to hand-held devices. Designated staff carry a handheld device, which displays the location of the alarm that has been pulled. Pendants will also be offered as needed. The community’s smoke detectors, sprinklers and carbon monoxide detectors are hard wired and were installed within the past 12 months. The fire extinguishers are located on every floor in each building and were observed to be fully charged and serviced. 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. The LPA observed the Ombudsman Poster and DSS Complaint Poster throughout the community.

Kitchen: The community had a sufficient supply of seven-day nonperishable food at the time of the visit. Emergency supply is adequate Appliances were clean and appeared functional. Facility uses Sysco Foods for food deliveries, and delivery takes place twice a week. Snacks and beverages are available for residents in the Bistro. Food is prepared in the main kitchen, and will be delivered to the Memory Care Unit.

Grounds: Community has a twelve (12) passenger van for transportation needs. There was a fountain and a waterfall feature observed in the courtyard on the garden level, however there was no water at this time due to city's water restrictions. The garden level has a covered outdoor area with furniture for resident use

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022

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: 09/02/2022

NARRATIVE

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Infection Control: The community has a central entry point for symptom screening and temperature checks for staff and visitors. There is hand sanitizer available throughout the community. The community has an adequate supply of Personal Protection Equipment (PPE) and the community is able to obtain additional supplies as needed. If needed, the community has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The community has a record of staff vaccinations and understands that they will need to maintain vaccination records for all residents that are vaccinated.

Applicant will be required to complete the following corrections and submit documentation within 10 days:

- Photos of the finished salon.

- Documentation of completed window screenings on all rooms.
- Photos of the completed drywall in the Wellness Center on the 2^nd floor
- Three-day temperature log, documenting temperature ranges for all resident rooms and common restrooms.
Upon receipt of the above items, physical plant will be in compliance with Title 22 regulations.

Exit interview held, documents given.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022

LIC809 (FAS) - (06/04)

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