565850268-9-14-2023-29-AS-ECOZ-CVNT6D-20230914142658

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850268
Report Date: 09/14/2023
Date Signed: 09/14/2023 02:28:58 PM

Document Has Been Signed on 09/14/2023 02:28 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:	RESIDENCE AT DEAN LLC, THE		FACILITY NUMBER:	565850268
ADMINISTRATOR:	LIMBO, JOSEPHINE		FACILITY TYPE:	740
ADDRESS:	4032 DEAN DRIVE		TELEPHONE:	(805) 654-0580
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY:	5	CENSUS: 4	DATE:	09/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Alex Tucson		TIME COMPLETED:	02:30 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	Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit at 9:00 a.m. When the LPA arrived, there was three staff and four residents present. The LPA was greeted by Caregiver Blesilda Espina and informed them of the reason for the visit. Administrator Alex Tecson shortly arrived. At 09:45am the LPA conducted a tour of the physical plant with administrator Alex Tecson. The following was noted: Facility is a single-story residence that consists of four (4) resident bedrooms and two (2) bathrooms. There is one (1) additional bedroom for staff use. LPA observed (2) fully charged fire extinguishers, however one was last serviced on 7/12/22 and the other did not have a service tag. All smoke alarms and carbon monoxide detector were tested and functioned properly during time of visit. LPA observed all required postings in front of the laundry 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: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. 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 under the sink. Bedrooms: The resident bedrooms were properly furnished with at least one chair, night stand 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 clean, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats in all bathrooms. Residents have sufficient amounts of supplies for personal hygiene. At 9:59 a.m. the hot water was measured in the communal bathroom during physical plant tour, at 116.5 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: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

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: RESIDENCE AT DEAN LLC, THE	FACILITY NUMBER: 565850268
	VISIT DATE: 09/14/2023

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 72 degrees.

Garage: The garage is where additional non-perishable emergency food items are held. Cleaning supplies and disinfectants are kept in the garage. The garage is locked and inaccessible to the residents in care.

Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises.

File review: A review of facility files was initiated at 10:25 a.m. and the following was observed.
The LPA reviewed four (4) of four (4) resident Files. The LPA observed all four resident files to be missing a reappraisal needs and services plan documenting changes in the resident's physical, medical, mental, and social condition. The LPA also observed one out of four residents (R1) was missing a pre-admission appraisal. The LPA observed documentation of Infection Control, and Disaster prevention however, there was no documentation of any disaster drill. The LPA reviewed five (5) out of six (6) staff files. All staff files reviewed appeared complete and current. The LPA obtained Client Roster and Staff Roster.

Interviews: At 12:00 p.m. the LPA conducted two (2) resident and two (2) staff Interviews. No immediate concerns were voiced during the visit.

Medication audit: Medications review began at 12:30 p.m.; medications are centrally stored and locked in a cabinet in the common area; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record, however, start dates for all medications of all four residents was not documented. A conversation was held between the LPA and administrator Alex of the importance of best practice in writing a start date for all medications. Administrator Alex stated that moving forward, the start date for all medications will be documented.

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 Alex Tecson.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/14/2023 02:28 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: RESIDENCE AT DEAN LLC, THE	FACILITY NUMBER: 565850268
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(b)(15)

Resident Records

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. 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 as one out of four residents (R1) were missing a pre-admission apprasaisal and four residents were missing their appraisal/needs and services plan which poses a potential health and safety risk to persons in care.
	POC Due Date: 09/28/2023
	Plan of Correction
1 2 3 4	Administrator agrees to complete all residents appraisals and needs and services plans and submit proof to CCL by 9/28/23.

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 quarterly disaster drills were not documented for any shift which poses a potential health and safety risk to persons in care.
	POC Due Date: 09/28/2023
	Plan of Correction
1 2 3 4	Administrator stated that they will conduct a disaster drill for each shift on 9/15/23 and submit proof to CCL by 9/28/23.

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: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

LIC809 (FAS) - (06/04)

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