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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609849
Report Date: 09/09/2024
Date Signed: 09/09/2024 04:21:39 PM

Document Has Been Signed on 09/09/2024 04:21 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:PCS - FERNWOODFACILITY NUMBER:
567609849
ADMINISTRATOR/
DIRECTOR:		DANIEL, DADESIIFACILITY TYPE:
735
ADDRESS:515 FERNWOOD DRTELEPHONE:
(805) 307-1810
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY: 4CENSUS: 4DATE:
09/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:35 AM
MET WITH:Dadesii Daniel TIME VISIT/
INSPECTION COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced required annual visit to the above facility. LPA met with staff and explained the reason for the visit. Administrator Dadesii Daniel arrived shortly after.

Record Review: At 11:00 a.m., a review of facility files was initiated. Facility records are stored in the locked office. The LPA observed documentation of Infection Control, Disaster prevention and last Disaster drill (conducted on 09/05/2024). The LPA obtained Client Roster and staff roster. The LPA reviewed four (4) out of four (4) client files, including P&I money. The LPA observed five (5) out of eighteen (18) staff files. All documents reviewed appeared complete and current.

Medications: Medications review began at 12:50 p.m. for two (2) clients; medications are centrally stored and locked in a locked cabinet inside the locked medication room; medications are labeled and checked for expiration dates. The following was observed, during client #1's (C1's) review the LPA observed two medications not documented on the centrally stored medications and destruction record (CSMDR). Upon observation staff documented the medications. The LPA also observed C1's Olanzapine 5mg ODT with eight (8) days worth of medications, however based on the start date and quantity on the prescription label C1 should have five (5) days worth of medication. Upon observation, the administrator stated that C1 had recently visited their family and staff did not document the quantity C1 came back with. The LPA also observed that the quantity for all of the clients had not been documented on the CSMDR.



The LPA toured the physical plant areas inside and out starting at 3:00 p.m. which included testing the smoke and carbon monoxide detectors which functioned properly. The fire extinguisher was last serviced on 4/16/2024.

(Continued on LIC 809-C)
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2024
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: PCS - FERNWOOD
FACILITY NUMBER: 567609849
VISIT DATE: 09/09/2024
NARRATIVE
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KITCHEN: Kitchen knives are stored in the locked drawer and in the locked medication room. The supply of dishes, utensils, pots, pans and drink ware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of nonperishable food is adequate. There are no pesticides/poisons/toxins stored in any food storage area or food preparation area. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Cleaning supplies are stored in a locked cabinet under the sink or locked in the garage. No flies or vermin were observed.

BEDROOMS: All client rooms were appropriately furnished and clean. Lighting in the rooms appeared adequate. There are 4 (four) total bedrooms for client use – all of which are private rooms.

RESTROOMS: There are two (2) bathrooms for client use. There is an additional bathroom which is used as storage of hygiene items and remains locked. The client bathrooms have showers with non-skid mats. The hot water temperature was measured at 93.9 F in one of the restrooms and 113.7*F in the second restroom.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. Common seating areas and dining room furniture was observed to be in good condition. Required postings were observed in the common hallway. The garage was observed locked and contained the laundry area and emergency food and water supply. The backyard has a covered outdoor area equipped with furniture for resident use. At 3:14 p.m. the LPA observed exposed wiring on the wall in the living room, near the ceiling.

INFECTION CONTROL: LPA spoke with the administrator regarding the facility’s infection control practices. LPA observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed.

INTERVIEWS: The LPA interviewed one (1) client and one (1) staff during today's visit.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview was conducted. Report and appeal rights were reviewed and emailed to the Administrator.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 09/09/2024 04:21 PM - It Cannot Be Edited


Created By: Esther Cortez On 09/09/2024 at 03:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PCS - FERNWOOD
FACILITY NUMBER: 567609849

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the LPA observed exposed electrical wiring in the living room which poses a potential health and safety risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
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Administrator temporarly covered the wiring, and agrees to have it fixed and submit proof to CCL by 09/20/2024
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as one of the restroom water temperature measured at 93.9 F which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2024
Plan of Correction
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Administrator agrees to adjust the water temparture and submit proof to CCL by 09/23/2024.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/09/2024 04:21 PM - It Cannot Be Edited


Created By: Esther Cortez On 09/09/2024 at 03:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PCS - FERNWOOD
FACILITY NUMBER: 567609849

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(7)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as 2 medications were not documented, and all of the clients medications quantity was not documented which poses a potential health and safety risk to persons in care.
POC Due Date: 09/23/2024
Plan of Correction
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Administrator will arrange for all staff that handles the medication record keeping to attend medication training, including how to complete the CSMDR and submit evidence of training to CCL by 9/23/24.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024


LIC809 (FAS) - (06/04)
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