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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850246
Report Date: 01/14/2025
Date Signed: 01/15/2025 08:40:59 AM

Document Has Been Signed on 01/15/2025 08:40 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:WALNUT GARDEN IIIFACILITY NUMBER:
195850246
ADMINISTRATOR:
ADMINISTRATOR/
DIRECTOR:		ILLOUZ, IZHAKFACILITY TYPE:
740
ADDRESS:12802 COLLINS STREETTELEPHONE:
(818) 624-1918
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY: 6CENSUS: 6DATE:
01/14/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
TIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Izhak IllouzTIME COMPLETED:
TIME VISIT/
INSPECTION COMPLETED:
04:28 PM
NARRATIVE
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Licensing Program Analyst (LPA) Valeria Conway conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20240328095338). The purpose of the visit is to issue citations for deficiencies observed during the initial complaint investigation unrelated to the complaint. During today’s visit, LPA met with Administrator Izhak Illouz and Licensee Arlene Ceballos and explained the reason for the visit.

During initial visit, LPA conducted a tour of the physical plant. At 10:28 a.m., LPA requested to review facility files, employee’s roster and residents’ files. Additionally, at 10:45 a.m., LPA obtained and reviewed copies of pertinent documentation relevant to the investigation. Between 11:20 a.m. and 12:54 p.m., LPA conducted interviews with facility staff, Administrator, and residents.

During today’s visit, the LPA conducted a brief physical plant tour, to ensure there are no health and safety concerns.



During the Department’s investigation, the following deficiencies were observed:

A review of the staff schedule for March and April 2024 was conducted to assess the allocation and coverage of staff. The schedule was organized into three columns. Each column detailed the coverage for three of the facilities operated by the Licensee, however, shift schedule was not noted. Interviews with the administrator indicate that the facility provides appropriate care for residents during the night shift. According to the administrator, staff conducts constant checks on residents throughout the night.

Continued on LIC 9099-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
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 01/15/2025 08:41 AM - It Cannot Be Edited


Created By: Valeria Conway On 04/03/2024 at 04:34 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: WALNUT GARDEN III
FACILITY NUMBER: 195850246

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/12/2024
Section Cited
CCR
87355(e)(1)

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87355: All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
This requierment is not met as evidence by:
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Administratorwill have S1 finguerprinted and associated to the facility and send prof to LPA.
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Based on records reviewed staff #1 has been working at the facility but does not have backround clearance and it is not associated to the facilit, which poses and immediate safety risk to residents in care
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Type A
01/17/2025
Section Cited
CCR87411(a)

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Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by:
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The licensee will submit a Personnel Report form LIC500 which reflects 24/7 adequate staff coverage. Also include the administrator’s and designated substitute’s days/hours at the facility. Submit proof to CCL by POC due date
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Based on records review and interviews, the licensee did not comply with the section cited above. There is no staff coverage from 7:00pm to 7:00am, which poses an immediate health and safety risk to residents in care.
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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: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


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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: WALNUT GARDEN III
FACILITY NUMBER: 195850246
VISIT DATE: 01/14/2025
NARRATIVE
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Continued from LIC 9099-C

The facility did not submit a Special Incident Report (SIR) to Community Care Licensing (CCL) to notify that Resident #1 (R1) sustained a fall resulting in a fractured wrist on 03/27/2024.

Licensee did not update R1’s appraisal needs and services plan to document R1’s change of condition which included behavioral issues and aggression which required medication adjustment.

A review of R1’s Physician Report revealed the report was not complete as the physician’s signature and date were missing and the section for authorization for release of medical information was blank.

During the initial visit on 04/03/2024, LPA observations and record reviewed revealed that Staff #1 (S1) currently working at the facility however S1 is not fingerprint cleared nor associated to the facility. Furthermore, a review of Guardian system and the staff roster revealed that Staff #2 (S2) is fingerprinted but not associated to the above facility.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 809-D)


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

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/15/2025 08:41 AM - It Cannot Be Edited


Created By: Valeria Conway On 01/14/2025 at 01:10 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: WALNUT GARDEN III
FACILITY NUMBER: 195850246

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/28/2025
Section Cited
CCR
87463(b)

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87463(b) Reappraisals (b) The reappraisal shall document significant changes in the resident's physical, ..., including those required to be documented as specified in Section 87466, Observation of the Resident. This requirement is not met as evidenced by:
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The licensee will submit a plan describing how you will ensure the resident appraisals are updated when there is a change of condition to reflect the current needs of the resident. Submit proof to CCL by POC due date
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Based on records review, the licensee did not comply with the section cited above. Licensee did not update R1’s appraisal needs and services plan to document R1’s change of condition which included behavioral issues and aggression which required medication adjustment, which posed a potential health and safety risk to residents in care.
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Type B
01/28/2025
Section Cited
CCR87458(a)

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87458(a) Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional ... kept in the resident's record. This requirement is not met as evidenced by:
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The licensee will submit a plan how you will ensure resident documents are complete, including signatures and dates. Submit proof to CCL by POC due date
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Based on record review, the licensee did not comply with the section cited above. R1’s medical assessment was missing physician signature and date, and the section for authorization for release of medical information was blank, which posed a potential health and safety risk to residents in care.

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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: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


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Document Has Been Signed on 01/15/2025 08:41 AM - It Cannot Be Edited


Created By: Valeria Conway On 01/14/2025 at 03:56 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: WALNUT GARDEN III
FACILITY NUMBER: 195850246

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/28/2025
Section Cited
CCR
87211(a)(1)(B)

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87211(a)(1)(B) Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted to the licensing agency and to the person responsible... events specified in (A) through (D) below….. (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.
This requirement is not met as evidenced by:
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The licensee will submit a plan describing how you will comply with reporting requirements. Submit proof to CCL by POC due date
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Based on records review, the licensee did not comply with the section cited above. Licensee did not submit an incident report when R1 fell and fractured wrist, which posed a potential health and safety risk to residents in care.
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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: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


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