<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850091
Report Date: 02/02/2022
Date Signed: 02/02/2022 03:03:48 PM

Document Has Been Signed on 02/02/2022 03:03 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:PRESERVE AT WOODLAND HILLS, THEFACILITY NUMBER:
195850091
ADMINISTRATOR:EILEEN ESQUIVELFACILITY TYPE:
740
ADDRESS:6221 FALLBROOK AVENUETELEPHONE:
(747) 226-5834
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 60CENSUS: 9DATE:
02/02/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Megan Cordova, Business Office ManangerTIME COMPLETED:
03:15 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) Elsie Campos conducted an unannounced Case Management-Deficiencies inspection visit at the facility today due to deficiencies observed during the investigation of complaint control # 29-AS-20220103170508.

During today’s investigation, the LPA observed accessible cleaning supplies under the kitchenette sink in the resident dining area at 9:38 a.m.

At 9:40 a.m., the LPA observed (4) accessible alcoholic beverage bottles in the kitchenette mini fridge in the resident dining area.

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

Exit interview conducted, today's reports and appeal rights were reviewed and issued. Civil penalties assessed.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2022
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 2
Document Has Been Signed on 02/02/2022 03:03 PM - It Cannot Be Edited


Created By: Elsie Campos On 02/02/2022 at 02:37 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: PRESERVE AT WOODLAND HILLS, THE
FACILITY NUMBER: 195850091

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/02/2022
Section Cited
CCR
87705(f)(2)

1
2
3
4
5
6
7
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 cleaning supplies and disinfectants.
1
2
3
4
5
6
7
The Buisness Office Manager agreed to do the following:
1. Items were secured during today’s visit. Plan of Correction met.

This is a repeat violation. Civil penalty of $250
assesed.
8
9
10
11
12
13
14
This requirement is not met as evidenced by:
Based on observation, the licensee did not comply with the section cited above, as items were accessible to residents with dementia, which poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Elsie Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2