565850325-6-13-2024-29-AS-BBAI-D67UUD-20240613155322

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850325
Report Date: 06/13/2024
Date Signed: 06/13/2024 03:54:33 PM

Document Has Been Signed on 06/13/2024 03:54 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:	WISDOM & GRACE SENIOR CARE		FACILITY NUMBER:	565850325
ADMINISTRATOR:	ALVIZURES, WALFRE A.		FACILITY TYPE:	740
ADDRESS:	4031 APRICOT RD.		TELEPHONE:	(818) 335-2355
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	6	CENSUS: 5	DATE:	06/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Walfre Alvizures		TIME COMPLETED:	04:15 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) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. Upon arrival LPA met with staff and explained the reason for the visit. Administrator Walfre Alvizures arrived shortly after. The LPA 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. LPA began the inspection in the kitchen/food service area at 10:40 a.m. Knives are stored in a locked cabinet underneath the sink. Kitchen appliances observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food properly stored. Cleaning supplies were observed locked and inaccessible under the kitchen sink. At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature of 74 degrees Fahrenheit. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. The fire extinguishers were fully charged and were last serviced 03/11/2024. All exits have functioning auditory devices and were operational at the time of the visit. The LPA observed required postings throughout the common space. The backyard has a covered outdoor area equipped with furniture for resident use. The LPA observed one (1) self-latching gate with clear passageways clear of obstruction. There were no bodies of water noted. LPA observed two (2) sheds, both were observed to be inaccessible to residents in care. LPA observed both sheds to store extra furniture, medical equipment and other items for facility use. There is a separate laundry room that was observed inaccessible for residents at the time of the visit.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024

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 06/13/2024 03:54 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: WISDOM & GRACE SENIOR CARE	FACILITY NUMBER: 565850325
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or 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 S1 and S2 did not have their clearance transferred to this facility which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/14/2024
	Plan of Correction
1 2 3 4	Licensee agreed to submit a transfer of a criminal record clearance for all staff not associated to the facility by 06/14/2024. Licensee will submit proof of clearance to LPA via email by eod 06/14/2024.

Type A

Section Cited

CCR

87463(c)

Reappraisals

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. 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 R1 and R5 did not have current Physician Reports (LIC 602) which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/14/2024
	Plan of Correction
1 2 3 4	Licensee agreed to submit a statment of understanding of regulation 87615(a) and obtain a new LIC 602 and submit to CCLD via email by COB 6/15/2024

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/13/2024 03:54 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: WISDOM & GRACE SENIOR CARE	FACILITY NUMBER: 565850325
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/13/2024

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 as R2, R3, R4 and R5 did not have a pre-admission appraisal on file which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/28/2024
	Plan of Correction
1 2 3 4	Licensee agreed to maintain full resident files in the facility. Licensee also agreed to submit proof of understanding and submit to LPA via email by EOD 06/28/2024.

Type B

Section Cited

CCR

87412(d)

(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. 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 the Administrator file is missing the following documents: Admin Cert, Education Verification, LIC 501, LIC 503, TB Test, LIC 9052, SOC 341a, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/28/2024
	Plan of Correction
1 2 3 4	Licensee agreed to maintain full Administrator file in the facility. Licensee also agreed to submit proof of understanding and submit to LPA via email by EOD 06/28/2024

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024

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: WISDOM & GRACE SENIOR CARE	FACILITY NUMBER: 565850325
	VISIT DATE: 06/13/2024

NARRATIVE

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The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are six (6) designated resident rooms. One wing of the home is designated as a private staff wing where staff reside. LPA observed it to be empty at this time. The resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in each restroom between 105 - 120 degrees Fahrenheit.

Records review began at 11:30am. Five (5) resident records were reviewed for the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, appraisals, and current needs and services plan.

At approx 11:30am, LPA observed Resident #1 (R1), Resident #2 (R2), Resident #3(R3), Resident #4(R4) and Resident #5 (R5), to have incomplete files. Missing documents are specified on 809-D.

LPA reviewed staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, and current first aid certification.
At approx 12pm, LPA observed Staff #1 (S1) and Staff #2 (S2) to have criminal background clearance, but they were not associated to this facility. Administrator's file was missing the following - Education Verification, LIC 501, LIC 503, TB Test / Result, LIC 9052, SOC 341A .Last emergency disaster drill conducted last quarter. Administrator will conduct drill by end of month.

Medications review began at 02:00 p.m. The medications are centrally stored and locked in a cabinet inside the kitchen. Medications are labeled and checked for expiration dates. No errors found during medication audit.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of COVID. 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 an infectious disease. The facility’s policies and procedures as it pertains to infection control are adequate.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024

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: WISDOM & GRACE SENIOR CARE	FACILITY NUMBER: 565850325
	VISIT DATE: 06/13/2024

NARRATIVE

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Continued from 809-C

LPA obtained the following documents at the time of visit: LIC500 Personnel Report, LIC9020 Client Roster, a copy of the emergency disaster plan, and a copy of the facility’s liability insurance. Staff and residents were interviewed during the visit.

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 809-D). Civil Penalties assessed in the amount of $1,000. Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024

LIC809 (FAS) - (06/04)

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