565850187-9-26-2023-29-AS-ECOZ-CW2QSV-20230926122611

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850187
Report Date: 09/26/2023
Date Signed: 09/26/2023 12:26:48 PM

Document Has Been Signed on 09/26/2023 12:26 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:	451 COLUMBIA LLC		FACILITY NUMBER:	565850187
ADMINISTRATOR:	SHERMAN, GILLIANA		FACILITY TYPE:	740
ADDRESS:	451 COLUMBIA ROAD		TELEPHONE:	(805) 807-0663
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 5	DATE:	09/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Bernardito Suarez		TIME COMPLETED:	12:30 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	At 09:00 a.m. Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by Administrator Bernardito Suarez and informed them of the reason for the visit. At 09:20 a.m. the LPA conducted a tour of the physical plant with Administrator Suarez to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a single-story residence that consists of six (6) resident bedrooms, two (2) staff bedrooms and four (4) bathrooms. The LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced 06/12/2023. All smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed all required postings in the hallway near the entrance area. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Kitchen: During the facility tour at 9:22 a.m. the kitchen appeared clean and the appliances and fixtures functional. The LPA observed a sufficient amount of perishable and non-perishable food at the facility; Sharp objects are stored in a locked drawer to the right of the stove and cleaning supplies are stored in a locked cabinet. Bedrooms: The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Bathrooms: The LPA observed all bathrooms, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats in all bathrooms. The hot water was measured in the master bedroom #1 bathroom during physical plant tour. Hot water measured 107.0 degrees Fahrenheit, within the required limit of 105-120 degrees Fahrenheit. Report will continue on LIC809-C.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

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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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: 451 COLUMBIA LLC	FACILITY NUMBER: 565850187
	VISIT DATE: 09/26/2023

NARRATIVE

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Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. The facility maintained a comfortable temperature of 73 degrees. There were no obstructions and/or tripping hazards throughout the facility.

Surrounding Grounds (Outdoors) and Garage: The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There were no large bodies of water on the premises. The garage is locked and attached to the house

Infection Control: The home has an adequate supply of Personal Protection Equipment (PPE) and can obtain additional supplies. The community's cleaning protocol is sufficient. The community's policies and procedures pertaining to infection control were adequate.

Record Review: At 10:00 a.m. a review of facility files was initiated. The LPA reviewed five (5) of five (5) Resident Files. Out of the five files reviewed, LPA Cortez identified that two out of five residents (R1, R2) require an updated physician’s report, and three out of five residents require an updated appraisal/needs and services plan due to the diagnosis of dementia. Otherwise, all resident records were in order. The LPA reviewed five (5) out of five (5) staff files. All staff files appeared complete and current. The LPA observed documentation of Infection Control and Disaster prevention. Administrator stated quarterly disaster drills have not been conducted. The LPA obtained Client Roster and Staff Roster.

Medications: At 11:15 a.m. a medications review was initiated. Medications are centrally stored and locked in a cabinet in the kitchen; 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.
Interviews: At 11:40 a.m. the LPA conducted two (2) client, and two (2) staff Interviews. No immediate concerns voiced during the visit.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided to Administrator Bernardito Suarez

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/26/2023 12:26 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: 451 COLUMBIA LLC	FACILITY NUMBER: 565850187
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above as administrator could not provide documentation of disaster drills which poses a potential health and safety risk to persons in care.
	POC Due Date: 10/10/2023
	Plan of Correction
1 2 3 4	Administrator agreed to conduct a disaster drill for all shifts and submit documentation to CCL by the POC due date.

Type B

Section Cited

CCR

87705(c)(5)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in three out of five residents as R1, R2 AND R3 all require an updated needs and services plan and R1 and R2 require an updated Physicians report which poses a potential health and safety risk to persons in care.
	POC Due Date: 10/10/2023
	Plan of Correction
1 2 3 4	Administrator agrees to get an updated LIC602 for R1 and R2 and an updated needs and service plans for R1, R2 and R3.

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 Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC809 (FAS) - (06/04)

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