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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850091
Report Date: 08/13/2024
Date Signed: 08/13/2024 03:26:44 PM

Document Has Been Signed on 08/13/2024 03:26 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:PRESERVE AT WOODLAND HILLS, THEFACILITY NUMBER:
195850091
ADMINISTRATOR/
DIRECTOR:		MICHAEL OWENSFACILITY TYPE:
740
ADDRESS:6221 FALLBROOK AVENUETELEPHONE:
(747) 226-5834
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 60CENSUS: 40DATE:
08/13/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:46 AM
MET WITH:Trevin WillisTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analysts (LPAs) Angela Barutyan and Emily Peraldi arrived at the facility unannounced to conduct a Case Management - Annual Continuation visit at 9:46AM, continuing the inspection that began on 08/07/2024. LPAs met with staff and Executive Director (ED) Trevin Willis and explained the reason for the visit.

RECORD REVIEW: LPAs began record review at 10:10AM. LPAs reviewed 5 (five) resident files for documents including, but not limited to: health screening, TB test, physician’s report, needs and service appraisal, and personal rights. All resident files reviewed were complete.

MEDICATION REVIEW: Medications are locked and centrally stored in the medication office. At 11:35AM, medications for 4 (four) residents were reviewed. All medications are labeled and maintained in compliance with label instructions, and state and federal law. All medications reviewed were recorded on the centrally stored medication and destruction record.

During today's visit, LPAs obtained a copy of the facility's liability insurance.

No deficiencies were observed during the inspection. A copy of the report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2024
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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