567610056-7-27-2023-29-AS-ECOZ-CU5VFC-20230727162342

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567610056
Report Date: 07/27/2023
Date Signed: 07/27/2023 04:25:45 PM

Document Has Been Signed on 07/27/2023 04:25 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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	APPLEGATE @ BERKSHIRE		FACILITY NUMBER:	567610056
ADMINISTRATOR:	CARMONA, RUBEN		FACILITY TYPE:	740
ADDRESS:	2010 FULLBROKE DRIVE		TELEPHONE:	(805) 870-4400
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91362
CAPACITY:	6	CENSUS: 5	DATE:	07/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:20 AM
MET WITH:	Irma Carmona-Licensee		TIME COMPLETED:	04:30 PM

NARRATIVE

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At 8:20 a.m. Licensing Program Analyst (LPA) Esther Cortez arrived unannounced to conduct a required annual visit. When the LPA arrived, there was two staff and four clients present. The LPA was greeted by Caregiver Patrick and informed them of the reason for the visit. Licensee Irma Carmona shortly arrived.

At 09:00 a.m. the LPA conducted a tour of the physical plant with Licensee Irma 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, two (2) staff rooms and seven (7) bathrooms. The LPA observed fully charged fire extinguishers last serviced on March 21, 2023. All smoke alarms and carbon monoxide detector were tested and functioned properly during time of visit. LPA observed all required postings throughout the facility. The facility accepts residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit.

KITCHEN: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. The LPA observed a sufficient amount of perishable and non-perishable food at the facility; Sharp objects and chemicals are locked and inaccessible.

BEDROOMS: The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets.

RESTROOMS: Resident restrooms were clean and sanitary with grab bars and non-skid surfaces. At 9:54 a.m., water temperature measured at 107.1 Fahrenheit.

REPORT WILL CONTINUE ON LIC809-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

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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Document Has Been Signed on 07/27/2023 04:25 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: APPLEGATE @ BERKSHIRE	FACILITY NUMBER: 567610056
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(a)

Reappraisals

(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: 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 in 5 out of 5 residents as all residents did not have appraisals to reflect significant changes, which posed a potential health and safety risk to residents in care.
	POC Due Date: 08/10/2023
	Plan of Correction
1 2 3 4	The licensee agrees to complete appraisal needs and services plan for all residents and submit proof to CCL by 8/10/2023.

Type B

Section Cited

CCR

87411(c)(1)

87411(c)(1) Personnel Requirements-General. Staff shall receive first aid training from persons qualified by such agencies as the American Red Cross. 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 First aid for one staff (S1) expired 4/13/22 which poses a potential health and safety risk to persons in care.
	POC Due Date: 08/10/2023
	Plan of Correction
1 2 3 4	The licensee agress to submit S1's updated first aid by 8/10/2023.

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: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/27/2023 04:25 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: APPLEGATE @ BERKSHIRE	FACILITY NUMBER: 567610056
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(a)

Reappraisals

(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date:
	Plan of Correction
1 2 3 4

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: APPLEGATE @ BERKSHIRE	FACILITY NUMBER: 567610056
	VISIT DATE: 07/27/2023

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COMMON SPACES: These included the backyard, living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. The facility maintained a comfortable temperature of 75 degrees. The backyard and exterior area of the facility had furniture and a covered area for resident use. There were no bodies of water noted at the time of the visit. All cleaning supplies are stored in locked cabinets. The garage is locked and inaccessible to the residents in care.

INFECTION CONTROL: There is a central entry point for universal screening and temperature checks. There is sanitizer available for use throughout the facility. There is an adequate supply of Personal Protection Equipment (PPE). The policies and procedures pertaining to infection control were adequate.

FILE REVIEW: A review of facility files was initiate at 10 a.m. and the following was observed.
The LPA observed documentation of Infection Control, Client Roster, and Staff Roster. The LPA reviewed five (5) of five (5) resident Files. The LPA observed all five resident files to be missing a reappraisal documenting changes in the resident's physical, medical, mental, and social condition. The LPA reviewed five (5) out of nine (9) staff files. Out of the nine files, the LPA identified that one staff (S1) had an expired first aid, expired on 4/13/2022.

INTERVIEWS: During the visit the LPA interviewed four (4) residents and four (4) staff. No immediate concerns voiced at this time.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit interview conducted and copy of the report and appeal rights were provided to the house manager per the Licensees direction.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

LIC809 (FAS) - (06/04)

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