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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609601
Report Date: 10/16/2024
Date Signed: 10/17/2024 08:30:03 AM


Document Has Been Signed on 10/17/2024 08:30 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:ARIANAH PLACE INCFACILITY NUMBER:
567609601
ADMINISTRATOR:GUEVARRA, ESTILITOFACILITY TYPE:
740
ADDRESS:53 WALES STREETTELEPHONE:
(805) 870-4518
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 6DATE:
10/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Erlinda GonzalezTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at approximately 9:00 a.m. When the LPA arrived, there was two (2) staff members and six (6) residents present. The LPA was greeted by Caregiver, Ashley Cabaneros. and the Administrator, Erlinda Gonzales. LPA informed them of the reason for the visit. Entrance Interview.

At 9:53 a.m. the LPA and the 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 noted: Facility is a single-story residence that consists of six (6) resident bedrooms and three (3) bathrooms. There are two (2) staff rooms. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. During today’s visit the LPA obtained the LIC500 (Personnel Report), LIC9020 (Client Roster) and Liability Insurance. Last emergency drill was conducted on 09/01/2024.

Bedrooms: All residents' bedrooms were properly furnished with at least one chair, a bed, night stand, chests of drawers, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. The bedrooms were large enough to allow for easy passage between the beds and furniture. In addition, no bedroom was used as a passageway to another room, bath, or toilet. All rooms were free of odors. All window screens were clean and maintained in good repair. Linens are kept in the closet and each room contains additional linens in resident closets.

Continued on LIC 809-C
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria ConwayTELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


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: ARIANAH PLACE INC
FACILITY NUMBER: 567609601
VISIT DATE: 10/16/2024
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Continued from LIC 809

Bathrooms: LPA observed all bathrooms were clean, sanitary and in operating condition. The bathrooms were sufficiently stocked with soap and paper towels 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. Between 10:00 a.m. and 10:33 a.m. hot water was measured in all three (3) bathrooms. All bathrooms were within the required limit of 105-120 degrees Fahrenheit.

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 blocked by a tv console and inaccessible to residents. The facility maintained a comfortable temperature of 71 degrees. LPA observed cameras throughout the common areas only. Facility provides sufficient space to accommodate both indoor and outdoor activities. LPA observed a working phone available for residents use whenever needed. Smoke detector(s) and carbon monoxide detector were tested at 11:15 a.m. and operational at the time of the visit. The two (2) fire extinguishers were fully charged and were last serviced 12/01/2023. The LPA observed required postings throughout the common space.

Kitchen: Kitchen and food service area was inspected during the physical plant tour. Knives and cleaning supplies are stored inaccessible under the kitchen sink. Kitchen appliances were in operable condition during today’s visit. The facility has a sufficient supply of perishable and non-perishable food. At 10:45 a.m., hot water temperature measured at 110 degrees Fahrenheit. LPA observed a complete First Aid Kit and its manual in the kitchen.

Surrounding Areas: The front yard is free of obstructions. The backyard has an outdoor area equipped with furniture and shade for client use. There is a side gate for resident use and is single latched. No bodies of water noted at the time of the visit.



Garage: The garage is where the washer and dryer are held. Cleaning supplies and disinfectants are kept in locked cabinets in the garage. All cleaning compounds were stored in areas separately from food supplies. Additionally, LPA observed emergency food and emergency water inside the garage. LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed.
Continued on LIC 809-C
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria ConwayTELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ARIANAH PLACE INC
FACILITY NUMBER: 567609601
VISIT DATE: 10/16/2024
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Continued from LIC 809-C

File review: A review of facility files was initiate at 11:43 a.m. and the following was observed. LPA reviewed six (6) residents’ files. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All residents’ documents reviewed appeared complete and current. Four (4) staff files including the administrator’s were reviewed. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. LPA obtained LIC 500 (Personnel Report) dated on 09/01/2024. A comparison was conducted between the information provided and the results from the Guardian Background Check report, which was ran today, 10/16/2024. On the LIC 500, LPA observed Staff #1 (S1) listed as a Reliever/Caregiver. LPA determined that S1 has a background clearance however is not properly associated to the facility. Records reviewed confirmed that S1 is associated to the licensee’s other facilities. Furthermore, LPA observed Administrator’s CPR certificate has expired. The administrator will renew the certification and provide a copy to the LPA upon completion. All other files reviewed appeared complete and current.

Medications: Medications review began at 2:00 p.m.; medications are centrally stored and locked in a cabinet in the kitchen. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

Interviews: LPA conducted interviews between 9:45 a.m. and 1:30 p.m., the LPA conducted two (3) staff and two (2) residents’ interviews.


Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Civil penalty was issued in the amount of $500. Administrator was informed that failure to correct deficiencies may result in additional civil penalties.

Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria ConwayTELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/17/2024 08:30 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: ARIANAH PLACE INC
FACILITY NUMBER: 567609601

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024

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
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Based on observation, interview and record review, the licensee did not comply with the section cited above when S1 was listed on LIC500 as a caregiver working 5 days a week without being associated, which posed an immediate safety risk to residents in care. CIVIL PENALTY ISSUED.
POC Due Date: 10/16/2024
Plan of Correction
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Licensee agrees to associate S1 to this facility as soon as possible. Administrator understand that S1 may not work in the facility until they are associated.
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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria ConwayTELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4