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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609955
Report Date: 10/07/2022
Date Signed: 10/07/2022 05:52:29 PM


Document Has Been Signed on 10/07/2022 05:52 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, THEFACILITY NUMBER:
567609955
ADMINISTRATOR:TECSON, ALEXANDERFACILITY TYPE:
740
ADDRESS:4656 VARSITY STTELEPHONE:
(805) 654-0585
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:6CENSUS: 4DATE:
10/07/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Alexander TecsonTIME COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analyst ( LPA) Angel Ascencio conducted a Case Management visit to the above facility. LPA met with Administrator Alexander Tecson at 10:00 a.m.

During facility tour at 9:45 a.m. and 9:46 a.m., LPA Ascencio along with staff observed an unlocked, open cabinet with Citalopram HBR 20 mg tablet, Metoclopramide 5 mg tablet, Vitamin B-1 100 mg and two medication pill holders that contained unlabeled medication in another drawer accessible to residents in care. Staff stated the cabinet and drawers should be locked at all times but was not at the time because they were helping with resident care. At 09:48 a.m., LPA Ascencio observed a kitchen knife, a peeler and can opener accessible to persons in care. Staff stated they had used the knife in the morning and were going to wash and lock it up. At 09:53 a.m., LPA observed Clorox wipes and disinfectants in a resident restroom accessible to residents in care. Staff stated the family uses the disinfectant to clean the restrooms. At 09:58 a.m., LPA observed Biotene dry mouth oral rinse, and Perineal Skin Cleanse in Room # 4 accessible to residents in care.


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 $500.00.

Exit interview conducted, today's reports, civil penalty and appeal rights were reviewed and emailed to the Administrator.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2022
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 3


Document Has Been Signed on 10/07/2022 05:52 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: 10/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/10/2022
Section Cited

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87705 Care of Persons with Dementia (f)(2) (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:
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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, cleaning supplies and disinfectants accessible to residents which poses an immediate health, safety and personal rights risk to persons in care.
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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 HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 10/07/2022 05:52 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: 10/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/10/2022
Section Cited

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87705 Care of Persons with Dementia(f)(1) 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:
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Based on LPA's observation and record review, the licensee did not comply with the section cited above as kitchen knife was observed in an unlocked kitchen drawer which poses an immediate health, safety and personal rights risk to persons in care.
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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 HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3