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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
567609955
Report Date:
08/31/2022
Date Signed:
08/31/2022 03:35:05 PM
Document Has Been Signed on
08/31/2022 03:35 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:
VARSITY MANOR, LLC, THE
FACILITY NUMBER:
567609955
ADMINISTRATOR:
TECSON, ALEXANDER
FACILITY TYPE:
740
ADDRESS:
4656 VARSITY ST
TELEPHONE:
(805) 654-0585
CITY:
VENTURA
STATE:
CA
ZIP CODE:
93003
CAPACITY:
6
CENSUS:
4
DATE:
08/31/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
01:15 PM
MET WITH:
Alexander Tecson
TIME COMPLETED:
03:33 PM
NARRATIVE
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Licensing Program Analyst (LPA) JoAnn Rosales conducted a Required 1 - Year visit to this facility. LPA met with Administrator Alexander Tecson.
LPA conducted a facility tour to inspect for infection control practices. Infection control practices were discussed with the Administrator. An inspection of the common areas, resident rooms and restrooms were conducted. LPA observed hot water temperature at 135.2 degrees F. in resident bathroom. There is an adequate amount of perishable food. PPE supplies were observed. LPA observed the fire extinguishers fully charged. The smoke detectors and carbon monoxide detectors were tested and operable. LPA observed appropriate lighting in residents rooms. Outdoor area toured- passageways are free of obstruction.
During facility tour with Administrator at 1:28 pm LPA observed scissors and cough drops in an unlocked kitchen drawer accessible to residents.
During facility tour with Administrator at 1:31 pm LPA observed readyprep CHG 2% chlorhexidine gluconate cloth in hallway cabinet accessible to residents.
During facility tour with Administrator at 1:33 pm LPA observed observed a room in the garage that is not on the facility sketch. Administrator stated that they have not been able to obtain the building permits.
During facility tour with Administrator starting at 1:40 pm LPA did not observe an adequate supply of non-perishable fruit as the facility had 10 small cans of fruit and non-perishable protein as the facility had 5 small cans of tuna, 3 small cans of sardines, 2 small cans of refried beans, 1 small can of luncheon loaf, and 1 small can of pork luncheon meat.
Continued on 809C
SUPERVISOR'S NAME:
Kristin Heffernan
TELEPHONE:
(818) 596-4493
LICENSING EVALUATOR NAME:
Joann Rosales
TELEPHONE:
(626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE:
08/31/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/31/2022
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
CCLD Regional Office
,
21731 VENTURA BLVD. #250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
VARSITY MANOR, LLC, THE
FACILITY NUMBER:
567609955
VISIT DATE:
08/31/2022
NARRATIVE
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During facility tour at 1:50 pm with Administrator LPA observed hot water temperature at 135.2 degrees F. in resident bathroom.
During facility tour with Administrator at 2:24 pm LPA observed mentholatum ointment in resident #1 (R1)'s bedroom accessible to residents.
Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):
Civil penalty assessed in the amount of $250.00.
Exit interview conducted, today's reports, civil penalty and appeal rights were reviewed and emailed to the Administrator.
SUPERVISOR'S NAME:
Kristin Heffernan
TELEPHONE:
(818) 596-4493
LICENSING EVALUATOR NAME:
Joann Rosales
TELEPHONE:
(626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE:
08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/31/2022
LIC809
(FAS) - (06/04)
Page:
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Document Has Been Signed on
08/31/2022 03:35 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:
VARSITY MANOR, LLC, THE
FACILITY NUMBER:
567609955
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/31/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above as the hot water temperature read at 135.2 degrees F. in resident bathroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/31/2022
Plan of Correction
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Administrator turned down water heater temperature during facility visit.
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and record review, the licensee did not comply with the section cited above as scissors were observed in an unlocked kitchen drawer which poses an immediate health and safety risk to persons in care.
POC Due Date:
09/01/2022
Plan of Correction
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Administrator placed scissors in a locked kitchen drawer during facility visit. Administrator stated that they will provide documentation of staff inservice regarding regulation 87705(f)(1) to CCL by 9/12/22.
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:
Kristin Heffernan
TELEPHONE:
(818) 596-4493
LICENSING EVALUATOR NAME:
Joann Rosales
TELEPHONE:
(626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE:
08/31/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/31/2022
LIC809
(FAS) - (06/04)
Page:
3
of
5
Document Has Been Signed on
08/31/2022 03:35 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:
VARSITY MANOR, LLC, THE
FACILITY NUMBER:
567609955
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/31/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA's observations and record review, the licensee did not comply with the section cited above as LPA observed over-the-counter medication which poses an immediate health risk to persons in care.
POC Due Date:
08/31/2022
Plan of Correction
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Staff placed items in an inaccessible location during the facility visit. Administrator stated that they will provide documentation of staff inservice regarding regulation 87705(f)(2) to CCL by 9/12/22.
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:
Kristin Heffernan
TELEPHONE:
(818) 596-4493
LICENSING EVALUATOR NAME:
Joann Rosales
TELEPHONE:
(626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE:
08/31/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/31/2022
LIC809
(FAS) - (06/04)
Page:
4
of
5
Document Has Been Signed on
08/31/2022 03:35 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:
VARSITY MANOR, LLC, THE
FACILITY NUMBER:
567609955
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/31/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
Prior to construction or alterations, all facilities shall obtain a building permit.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above as a room was observed in the garage without documentation of a building permit which poses a potential safety risk to persons in care.
POC Due Date:
09/12/2022
Plan of Correction
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Administrator stated that will go to the City of Ventura to obtain a building permit if they are unable to obtain the permit they will remove the room in the garage.
Type B
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above as the facility did not have a one week supply on non-perishable fruit and protein which poses a potential health and personal rights risk to persons in care.
POC Due Date:
09/06/2022
Plan of Correction
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Administrator stated that they will provide documentation of a a one week supply of non-perishable fruit and protein to CCL by 9/6/22.
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:
Kristin Heffernan
TELEPHONE:
(818) 596-4493
LICENSING EVALUATOR NAME:
Joann Rosales
TELEPHONE:
(626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE:
08/31/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/31/2022
LIC809
(FAS) - (06/04)
Page:
5
of
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