567609984-6-14-2024-29-AS-BBAI-D68TNK-20240614145254

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609984
Report Date: 06/14/2024
Date Signed: 06/14/2024 02:53:38 PM

Document Has Been Signed on 06/14/2024 02:53 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:	BUENAVILLE ASSISTED LIVING, LLC		FACILITY NUMBER:	567609984
ADMINISTRATOR:	TAPEL, NIDA A		FACILITY TYPE:	740
ADDRESS:	5629 PITTMAN ST		TELEPHONE:	(805) 210-2523
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	6	CENSUS: 4	DATE:	06/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Natalia Dela - House Manager		TIME COMPLETED:	03:30 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 Marilou Mallari was out of town at the time of the visit, but stated that House Manager Natalia Dela can sign for the report. 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 09:40 a.m. Knives are stored in a locked drawer to the left of the fridge. 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. 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 06/13/2024. 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 LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are four (4) designated resident rooms. The facility has one (1) designated staff bedroom that is maintained locked at all times. 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. There is a separate laundry room, which is kept locked at all times. Cleaning supplies and disinfectants are kept locked inside the laundry room. There is an attached garage that observed inaccessible to residents in care. LPA observed the garage to store emergency food supply, an additional fridge for extra food storage along with additional furniture and supplies for facility use. The backyard has a covered outdoor area equipped with furniture for resident use. The LPA observed one (2) self-latching gate with clear passageways clear of obstruction. There were no bodies of water noted.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BUENAVILLE ASSISTED LIVING, LLC	FACILITY NUMBER: 567609984
	VISIT DATE: 06/14/2024

NARRATIVE

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Continued from 809
Records review began at 10:30am. Four (4) 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. 10:45am, LPA observed that the Needs and Appraisals were not current for Resident #1 (R1), Resident #2(R2), Resident #3 (R3), and Resident #4 (R4).
LPA reviewed staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, and current first aid certification. All staff records were in order at this time. Emergency disaster drill was not conducted last quarter , but House manager stated they will be conducting a drill by the end of the month.

Medications review began at approximately 01:30 pm The medications are centrally stored in a hallway closet inaccessible to residents in care. Medications are properly documented on the centrally stored medications and destruction record.

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 a communicable disease. 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.

The LPA obtained the following documents at the time of visit: LIC500 Personnel Report, LIC9020 Client Roster, 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). 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: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3

Document Has Been Signed on 06/14/2024 02:53 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: BUENAVILLE ASSISTED LIVING, LLC	FACILITY NUMBER: 567609984
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

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 (4) out of (4) residents did not have current Needs and appraisal plans, 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 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

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. 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 an emergency disaster drill was not conducted last quarter, 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 conduct an emergendcy disaster drill by the end of the month and submit proof 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: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

LIC809 (FAS) - (06/04)

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