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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850285
Report Date: 05/24/2024
Date Signed: 05/24/2024 12:10:04 PM

Document Has Been Signed on 05/24/2024 12:10 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:FALLBROOK ASSISTED LIVINGFACILITY NUMBER:
195850285
ADMINISTRATOR/
DIRECTOR:		ASATRYAN, YULIYAFACILITY TYPE:
740
ADDRESS:5504 FALLBROOK AVENUETELEPHONE:
(818) 395-9535
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 6CENSUS: 4DATE:
05/24/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:27 AM
MET WITH:Yuliya AsatryanTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced at 8:27 AM for a Case Management – Annual Continuation inspection. The LPA met with facility staff Florencio Aguilon. Administrator was contacted via phone and arrived at 9:26 AM. LPA explained the reason for the visit.

During the Required 1-Year on 01/23/2024, LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility compliance of Title 22 Regulations. A brief tour of the physical plant was also conducted during today’s visit. No health and safety concerns were identified during today's tour. Administrator stated that on 03/20/2024 facility was approved for the Assisted Living Waiver (ALW).

RECORD REVIEW: During today’s visit, LPA reviewed staff files at approximately 9:52 AM. Staff records were reviewed for documents including, but not limited to staff training, fingerprint clearance, health screening, TB test result, and SOC 341 form. Record review and interview conducted revealed that reliever caregivers used by the facility are missing a health screening form (LIC 503) under Falbrook Assistant Living. Staff #1 (S1) and Staff #2 (S2) provided a LIC503 form with a different facility name showing negative TB test for both S1 and S2. Licensee agreed to have a new LIC503 under Fallbrook Assisted Living. A Technical Violation was issued explaining the importance of having records in order for each hired staff.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING/EMERGENCY DRILLS: During today’s visit, the LPA reviewed the facility's emergency disaster plan. Plan was observed to be complete and updated annually, as required. Last emergency drill was conducted on 05/23/2024. Residential Infection Control Plan was reviewed. LPA observed this plan to be complete and updated as of 01/02/2024.

Continued on LIC 809C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2024
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: FALLBROOK ASSISTED LIVING
FACILITY NUMBER: 195850285
VISIT DATE: 05/24/2024
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Continued from LIC 809.

MEDICATION REVIEW: The medication closet is locked and inaccessible to residents in care. Resident’s medication records are kept confidential and locked. At 11:35 AM LPA reviewed centrally store medication sheet and compared it to medication in hand for four (4) out of four (4) residents. At the time of the visit revealed no discrepancies were note.

INTERVIEWS: LPA interviewed two (2) staff members and one (1) resident. They don’t have any concern at the time of the visit.



No citations observed during today’s visit. Exit interview conducted. A copy of the report is provided

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
LIC809 (FAS) - (06/04)
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