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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850273
Report Date: 02/21/2024
Date Signed: 02/21/2024 01:13:10 PM


Document Has Been Signed on 02/21/2024 01:13 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:NAVITA RESIDENCES YOUNGFACILITY NUMBER:
565850273
ADMINISTRATOR:VIJAYAKUMAR, KARTHIGAFACILITY TYPE:
740
ADDRESS:2024 YOUNG AVETELEPHONE:
(805) 917-2025
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: DATE:
02/21/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Sheila PandeyTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced Case Management-Deficiency visit to address deficiencies observed during the complaint investigation of complaint # 29-AS-2023080809135 LPA met with the Administrator Sheila Pandey and explained the reason for the visit.

During the complaint investigation of complaint # 29-AS-20230808091357, the following deficiencies were observed: There was no incident report submitted to Community Care Licensing (CCL) for Resident #1’s (R1’s) fall on 08/06/2023. (R1) had an unwitnessed fall during the night on 08/06/2023, which resulted in multiple bruises and hospitalization. Staff #1 (S1) was working at the facility on 08/06/2023, however S1 was not associated to the facility until 10/27/2023. An Immediate Civil Penalty of $500 is issued today due to S1 not being associated to the facility on 08/06/2023.


Citations issued, Immediate Civil Penalty $500 issued, exit interview, appeal rights given.
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024
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 02/21/2024 01:13 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: NAVITA RESIDENCES YOUNG
FACILITY NUMBER: 565850273

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/26/2024
Section Cited
CCR
87355(e)(2)(f)

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Criminal Record Clearance
(e)All individuals subject to a criminal record review pursuant to ...(b) shall prior to working, residing or volunteering in a licensed facility: (2)Request a transfer of a criminal record...(f)Violation of Section 87355(e) shall result in ... of one hundred dollars ($100) per violation per day for a maximum of five (5) days by the department.This requirement is not met as evidenced by:
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The licensee will review Regulation 87355 Criminal Record Clearance and submit memo of understanding to CCL by due date of 03/01/2024.

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Based on record review, S1 was working at the facility on 08/06/2023, however S1 was not associated to the facility until 10/27/2023, which posed an immediate health and safety risk to residents in care.

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Type B
02/26/2024
Section Cited
CCR87211(a)(1)(A)

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(a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence… This requirement is not met as evidenced by:

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The licensee will submit an incident report for R1’s 08/06/2023 unwitnessed fall. Submit to CCL by due date of 03/012024.
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Based on record review, the facility did not submit an incident report for R1’s unwitnessed fall on 08/06/2023, which posed a potential health and safety risk to residents in care.
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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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024
LIC809 (FAS) - (06/04)
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