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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850387
Report Date: 10/04/2024
Date Signed: 10/04/2024 03:36:30 PM

Document Has Been Signed on 10/04/2024 03:36 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:LOVE & CARE BOARDING HOMEFACILITY NUMBER:
195850387
ADMINISTRATOR/
DIRECTOR:		VANOYAN, ERNAFACILITY TYPE:
740
ADDRESS:11949 STRATHERN STREETTELEPHONE:
(818) 389-1303
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 6DATE:
10/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:23 AM
MET WITH:Erna VanoyanTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:23 AM. LPA met with facility staff who contacted facility administrator Erna Vanoyan via telephone call. The facility administrator arrived to the facility at approximately 09:46 AM. Entrance interview conducted and the reason for the visit was explained.

Beginning at 09:46 AM, the LPA, along with facility administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN/LAUNDRY: The LPA observed the kitchen area to be clean. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured drawer to contain knives as well as a secured cabinet located under the sink which contained cleaning supplies. LPA observed a fire extinguisher located in the kitchen to be purchased on 06/10/2024. LPA observed the laundry to be located adjacent to the kitchen. LPA observed a secured cabinet in the laundry to contain detergent and extra cleaning supplies. LPA observed the laundry to contain adequate emergency food and water supplies.

BEDROOMS: There are four (4) bedrooms in the facility; two (2) are single occupancy rooms and two (2) are dual occupancy rooms. Bedroom number one (1) is designated as the bedridden approved room. LPA and facility administrator toured all four (4) resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Auditory alarms were observed on all facility exits.

Report Continued on LIC 809-C
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 10/04/2024 03:36 PM - It Cannot Be Edited


Created By: Trevor Byrne On 10/04/2024 at 01:59 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: LOVE & CARE BOARDING HOME
FACILITY NUMBER: 195850387

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

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 as one resident's medicatioons were prepped a week in advance utilizing a Sunday-Saturday medication organizer which poses a potential health and safety risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
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Licensee will submit a statement of understanding confirming they have reviewed CCR 87465 and will submit a statement that they will not prep medications more than one day in advance. Licensee will submit the required documents to CCL no later than POC due date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above as the last emergency disaster drill was not conducted quarterly which poses a potential health and safety risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
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Licensee will submit proof of completed emergency disaster drill to CCL no later than POC due date.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2024


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Document Has Been Signed on 10/04/2024 03:36 PM - It Cannot Be Edited


Created By: Trevor Byrne On 10/04/2024 at 01:59 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: LOVE & CARE BOARDING HOME
FACILITY NUMBER: 195850387

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(h)
Care of Persons with Dementia
(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.

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 aboveas the front gate / emergency exit gate to the facility failed to self latch which poses a potential safety risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
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Licensee will submit either, proof of repairs made to gate and proof of gate self latching or proof of scheduled repairs and an invoice of repairs to be completed. Licensee will submit the required proof to CCL no later than POC due date.
Type B
Section Cited
CCR
87307(a)
87307 Personal Accommodations and Services
(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above as one resident room contains three beds, one of which the facility administrator sleeps in to monitor residents at night which poses personal rights risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
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Licensee will dismantle the third bed in bedroom #4. Additionally licensee will submit a statement of understanding confirming that they understand that this is a potential violation of resident's rights. Licensee may submit an updated LIC500 showing nighttime awake staff to mitigate the risk of falls for residents in care. Licensee will submit the required documents to CCL no later than POC due date.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2024


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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: LOVE & CARE BOARDING HOME
FACILITY NUMBER: 195850387
VISIT DATE: 10/04/2024
NARRATIVE
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BEDROOMS: LPA observed bedroom number four (4) to contain three (3) beds. LPA asked the administrator who slept in the third bed and the administrator stated that it was for their use to monitor residents at night to reduce the risk of falls. LPA informed the administrator that this is a violation of CCR 87307(a). LPA informed administrator that staff are not allowed to sleep in resident rooms and that nighttime awake staff must be utilized.

BATHROOMS: There are two (2) bathrooms at the facility. One (1) bathroom is designated as shared resident bathroom. And one (1) bathroom is designated as a private resident bathroom. All bathrooms were observed to be clean and in good repair and all were equipped with nonskid surfaces. Grab bars were observed in all showers and near all toilets, all were properly secured. The water temperature was measured between 113.9 and 117 degrees Fahrenheit, which is in compliance regulation.


COMMON AREAS: This includes the living room. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contains an appropriately screened fireplace, a couch, and activities for resident use. LPA observed a hallway closet to contain extra linens and care supplies. LPA observed all required postings for the facility near the entry way.

OUTDOOR SPACE: The facility has one (1) emergency exit gate located in the front yard, LPA observed the facility’s emergency exit gate to fail to self-latch at the time of the visit. LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use.

RECORD REVIEW: Record review began at 10:21 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, first aid certification, consent forms, and personal rights. Three (3) staff files were reviewed. One staff file reviewed did not contain a first aid certification. Six (6) resident files were reviewed. All resident files reviewed contained all required documentation.

Report Continued on LIC 809-C
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024
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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: LOVE & CARE BOARDING HOME
FACILITY NUMBER: 195850387
VISIT DATE: 10/04/2024
NARRATIVE
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MEDICATION REVIEW: Medication review began at 11:44 AM. Medications are stored centrally and securely in a cabinet in the kitchen. LPA observed medications for one (1) resident to be prepared using a Sunday-Saturday medication organizer which is not in compliance with regulation. Medications for four (4) residents were observed. All medications observed were documented appropriately on their centrally stored medication and destruction record sheets.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the
facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are to be conducted quarterly; the facility’s last emergency disaster drill was conducted on 06/21/2024 which is not in compliance with regulations. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan were reviewed/updated annually by the facility’s administrator.

INTERVIEWS: LPA interviewed one (1) staff and three (3) residents. All residents interviewed stated that the staff treat them well and are attentive to their needs. No residents interviewed had concerns with the facility. The staff member interviewed was knowledgeable on their role and responsibilities, resident rights, the different forms of abuse and the appropriate reporting procedures for suspected abuse.

During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and liability insurance.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-Ds): Exit interview conducted and copy of the report was issued and appeal rights provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024
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Document Has Been Signed on 10/04/2024 03:36 PM - It Cannot Be Edited


Created By: Trevor Byrne On 10/04/2024 at 03:08 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: LOVE & CARE BOARDING HOME
FACILITY NUMBER: 195850387

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.613(c)(3)
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as one staff member that was left alone with clients in care did not have an active 1st aid certification in their file which poses a potential health and safety risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
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Licensee will submit proof of completed 1st aid certification for the identified staff member to CCL no later than the POC due date.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2024


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