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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850242
Report Date: 08/02/2023
Date Signed: 08/02/2023 06:18:14 PM


Document Has Been Signed on 08/02/2023 06:18 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:NAVITA RESIDENCES EDGEMONTFACILITY NUMBER:
565850242
ADMINISTRATOR:SHILA PANDEYFACILITY TYPE:
740
ADDRESS:1690 EDGEMONT DRTELEPHONE:
(805) 413-2455
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:6CENSUS: 5DATE:
08/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:06 AM
MET WITH:Shila PandeyTIME COMPLETED:
06:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 10:06AM. LPA initially met with facility staff. Administrator Shila Pandey was contacted via telephone and arrived at the facility at 10:30AM. Entrance interview conducted.

Beginning at 10:46AM, the LPA, along with Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed

Combination smoke and Carbon Monoxide detector was tested at 04:28PM and was functional at the time of the visit.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 7 (seven) total bedrooms; 1 (one) of which is designated as a staff room and 6 (six) are private resident rooms. Staff room was observed locked.

RESTROOMS: The LPA observed 3 (three) restrooms in the facility; 2 (two) are shared restrooms and one is a private restroom. Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperature was measured in all 3 (three) restrooms both in the morning and afternoon and measured lower than the required temperature. At 11:04AM, water temperature in the kitchen measured just above the minimum required temperature at 105.3 degrees Fahrenheit, but measured well below at 04:20PM.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. A fireplace was observed to be adequately screened and inaccessible to residents. Fire extinguisher was observed to be fully charged and purchased Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: NAVITA RESIDENCES EDGEMONT
FACILITY NUMBER: 565850242
VISIT DATE: 08/02/2023
NARRATIVE
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on 03/21/2023. Garage was observed locked and contained the laundry area, extra food, and additional storage.

OUTDOOR SPACE: The backyard has a shaded seating area for resident use. There were no bodies of water noted. At 11:19AM, LPA observed the outdoor exit gate to be locked. LPA spoke with the Administrator about the gate being an emergency route out of the facility and cannot be locked.

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food, as well as emergency food and water supply. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit.

RECORD REVIEW: Record review began at 11:31AM, records were reviewed for but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. 5 (five) resident records reviewed were complete and contained all required documents. LPA observed 2 (two) residents were identified as being bedridden on their physician's reports, however, the facility has fire clearance for 1 bedridden resident. 3 (three) staff files were reviewed; all 3 (three) staff files reviewed were complete.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, the LPA reviewed the facility’s infection control practices and emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency Disaster Plan was observed to be completed, but has not been reviewed annually. Emergency drills are conducted monthly, with the last documented drill on 06/30/2023.

MEDICATION REVIEW: Medications were observed locked in a cabinet adjacent to the kitchen. Review began at 02:55PM. Medications for 3 (three) residents were observed. All 3 (three) residents' medications were observed to be maintained and administered in compliance with regulation.

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Two (2) civil penalties were issued, totalling $1000. Exit interview conducted. A copy of the report and appeal rights were provided
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 08/02/2023 06:18 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: NAVITA RESIDENCES EDGEMONT
FACILITY NUMBER: 565850242

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as the facility has a fire clearance for 1 bedridden resident, however 2 residents' physician's reports and needs and service appraisals indicate bedridden status, which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/03/2023
Plan of Correction
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Administrator agreed to contact Resident #1 (R1)'s physician to clarify bedridden status and update CCL on the status by POC due date. Plan of correction will be revisited based on response from R1's physician.
Type A
Section Cited
CCR
87705(l)
Care of Persons with Dementia
(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above as the facility's exit gate was observed to be locked which poses an immediate safety and personal rights risk to persons in care.
POC Due Date: 08/02/2023
Plan of Correction
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Lock was removed during today's visit. POC cleared.
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: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6


Document Has Been Signed on 08/02/2023 06:18 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: NAVITA RESIDENCES EDGEMONT
FACILITY NUMBER: 565850242

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

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 as water temperature in all 3 bathrooms measured below 105 degrees, both in the morning and afternoon, which poses a potential health and safety risk to persons in care.
POC Due Date: 08/16/2023
Plan of Correction
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Administrator contacted the facility's maintenance person during today's visit. Hot water heater will be looked at and temperature adjusted to the required temperature. Administrator will the record water temperatures at various times of the day over the course of a 7 day period and log the temperature readings. Log will be provided to CCL by POC due date.
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: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6