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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191201966
Report Date: 09/25/2024
Date Signed: 09/26/2024 07:26:08 AM

Document Has Been Signed on 09/26/2024 07:26 AM - 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:MOTION PICTURE & TELEVISION FUNDFACILITY NUMBER:
191201966
ADMINISTRATOR/
DIRECTOR:		LORENA SORIAFACILITY TYPE:
740
ADDRESS:23388 MULHOLLAND DRIVETELEPHONE:
(818) 876-1208
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91364
CAPACITY: 241CENSUS: 142DATE:
09/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Martha GutierrezTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analysts (LPAs) Valeria Conway and Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at 9:30 A.M. Upon arrival LPAs met with Nursing Manager Martha Gutierrez and explained the reason for the visit. Administrator, Lorena Soria, couldn’t be present at the time of the visit; however, Nursing Manager is authorized to sign today’s report. Entrance interview.

The LPAs 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.

At 9:50 A.M., a tour of the physical plant was conducted. There are three separate residential areas for the licensed facility: Cottages, Lodge, and Villa. The Cottages are for higher functioning residents, the Lodge is assisted living, and the Villa is a mix of high functioning residents and assisted living. Required postings were observed in various common areas of the facility.

The following was observed for the three residential areas:

COMMON AREAS: LPAs inspected the common areas throughout the buildings. These included the library, activity rooms, and computer rooms. The common areas were observed to be properly furnished and relatively clean at the time of the visit. LPAs observed sanitizer readily available in areas with high touch surfaces. Dining room furniture was observed to be in good condition in each building. The facility maintained a comfortable temperature in each building. LPAs observed evacuation chairs in all stairwells. Smoke detector(s) and carbon monoxide detectors were operational at the time of the visit. Fire extinguishers were observed throughout the facility, fully charged and were last serviced 01/11/2024.

Continued on LIC 809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2024
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: MOTION PICTURE & TELEVISION FUND
FACILITY NUMBER: 191201966
VISIT DATE: 09/25/2024
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Continued from LIC 809

Last emergency disaster drill conducted quarterly; the last one was conducted on 09/12/2024. The last fire safety inspection was completed on 10/22/2023 and it was found to be in compliance with fire code regulations at the time of inspections.

KITCHENS: There are three (3) separate kitchens. Knives and sharp objects observed to be kept inaccessible to residents in care. Kitchen appliances appeared to be in operable condition. LPAs observed a sufficient supply of perishable and non-perishable food in each building. During the inspection, LPAs observed several expired items including a box of stuffing and two (2), 32 oz container of yogurt. Technical violation issued. Items were discarded at the time of the visit.

SORRUNDING GROUNDS; Facility is gated. Entry/exits were free of obstructions. There are several shaded areas with adequate outdoor furniture for resident use. The outdoor areas were clean and free of hazards. No bodies of water noted at the time of the visit. There are two (2) buildings with staff offices, a gym, and a pool for residents. Pool was locked and inaccessible to residents at the time of the visit.

BEDROOMS: LPAs inspected thirteen (13) randomly selected bedrooms throughout the Cottages, The Lodge and The Villa. The resident bedrooms were properly furnished and with sufficient lighting. At 10:15 A.M. LPAs observed Resident #1 (R1) sleeping on the floor. Staff stated R1 chooses not to have a bed. LPAs informed staff an exception request is need it. Starting at 10:15 A.M. LPAs measured hot water temperature in 13 randomly selected residents’ bedrooms. Hot water temperature measured within the required range of 105 - 120 degrees Fahrenheit. Resident bathrooms 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.




Continued on LIC 809-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
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: MOTION PICTURE & TELEVISION FUND
FACILITY NUMBER: 191201966
VISIT DATE: 09/25/2024
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RECORDS: Between 12:45 P.M. and 3:00 P.M., ten (10) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Ten (10) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order at this time.

MEDICATIONS: Medications review conducted during inspection. The medications are centrally stored and inaccessible to residents in care. Medications are properly documented on the centrally stored medications and destruction record. Medications appeared to be administer as prescribed during the inspection.

During the inspection the LPAs interviewed thirteen (13) residents and five (5) staff members.

LPAs obtained the following documents: Resident Census, Staff rooster, last emergency drill, vehicle registration for facility owned vans and last fire inspection.

The following citation is being cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/26/2024 07:26 AM - It Cannot Be Edited


Created By: Valeria Conway On 09/25/2024 at 03:59 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: MOTION PICTURE & TELEVISION FUND
FACILITY NUMBER: 191201966

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(3)(A)
Personal Accommodations and Services
(A) A bed for each resident, except that married couples may be provided with one appropriate sized bed. Each bed shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. Fillings and covers for mattresses and pillows shall be flame retardant. Rubber sheeting shall be provided when necessary.

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 by not applying for an exception for resident 1, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
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Licensee agreed to submit an exception for resident 1 not to have a bed in his room.
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:Desaree Perera
LICENSING EVALUATOR NAME:Valeria Conway
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024


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