565850307-2-22-2024-29-AS-SURA-D2PLKS-20240222074957

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850307
Report Date: 02/21/2024
Date Signed: 02/22/2024 07:51:09 AM

Document Has Been Signed on 02/22/2024 07:51 AM - 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:	CONEJO VALLEY HOME CARE		FACILITY NUMBER:	565850307
ADMINISTRATOR:	FITZGERALD, KEVIN		FACILITY TYPE:	740
ADDRESS:	2476 DRAYTON AVE		TELEPHONE:	(805) 558-2023
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 6	DATE:	02/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Melissa Briones		TIME COMPLETED:	06:30 PM

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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual inspection. The LPA was greeted by staff and informed them of the reason for the visit. Facility designated staff Melissa Briones arrived shortly thereafter.

The LPA and the staff 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.

KITCHEN: Knives and cleaning supplies are stored locked and inaccessible to residents. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable foods, and seven-day supply of non-perishable food. The fire extinguisher was purchased on 02/21/2024.

BEDROOMS: Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There was a linen closet in the hallway with extra towels and linens.

BATHROOMS: Bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature of 76 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The LPA observed required postings throughout the common space. The washer and dryer are located next to the medication closet. The laundry room is inaccessible to residents in care.

OUTDOOR AREA/GARAGE: The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate for client use and is single-latched. No bodies of water noted. The garage is attached to the property and is locked and inaccessible to residents. Cleaning supplies and disinfectants are kept locked in the garage.

Continues on LIC809C...

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 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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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: CONEJO VALLEY HOME CARE	FACILITY NUMBER: 565850307
	VISIT DATE: 02/21/2024

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RECORDS: Records review began at 1:55 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. Four (4) out of six files were missing the Identification and Emergency Contact form (LIC601). Five (5) out of six files were missing the Resident Appraisal (LIC603A) form. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Six (6) out of six files were missing the Health Screening Form (LIC 503), and one(1) out of six files was missing the Personnel/Employment form (LIC 501).

MEDICATIONS: Medications review began at 3:37 p.m. Medications are centrally stored and locked in a closet next to the laundry room; medications are labeled and were checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record form. No errors observed during the medication review.

INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

The LPA reviewed the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster

Deficiencies cited at this time. Exit interview conducted. A copy of the report and Appeal Rights were issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 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

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/22/2024 07:51 AM - 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: CONEJO VALLEY HOME CARE	FACILITY NUMBER: 565850307
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87415(a)

Night Supervision

(a) The following persons providing night supervision from 10:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures, shall be trained in first aid as required in Section 87465, Incidental Medical and Dental Care Services, and shall be available as indicated below to assist in caring for residents in the event of an emergency: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record reviewe, the licensee did not comply with the section cited above in as two out of out of two night staff are not trained in first aid as required, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/01/2024
	Plan of Correction
1 2 3 4	The Licensee(desiganted facility representative) has agreed to have staff trained in CPR and First Aid by the date on the POC. Licensee will email the department acopy of the first Aid and CPR certification card.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Sandra Urena	TELEPHONE: 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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Document Has Been Signed on 02/22/2024 07:51 AM - 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: CONEJO VALLEY HOME CARE	FACILITY NUMBER: 565850307
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87457(c)

Pre-Admission Appraisal

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. 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 as six out of six residents did not have a completed appraisal, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/01/2024
	Plan of Correction
1 2 3 4	The Licensee(desiganted facility representative) has agreed to have complete the Appraisal for each resident by the date on the POC. Licensee will email the department acopy of the appraisals..

Type B

Section Cited

HSC

1569.695(e)(4)

Other Provisions

(e) A facility shall have all of the following information readily available to facility staff during an emergency: (4) Contact information for the responsible party and physician for each resident. 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 as four out of six residents files didnot have a completed emergency form, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/01/2024
	Plan of Correction
1 2 3 4	The Licensee(desiganted facility representative) has agreed to have complete the Emergency ontact form for each resident by the date on the POC. Licensee will email the department acopy of the Emergecy form.

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: Sandra Urena	TELEPHONE: 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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