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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602669
Report Date: 12/21/2022
Date Signed: 12/21/2022 12:12:14 PM

Document Has Been Signed on 12/21/2022 12:12 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:LEISURE LIVINGFACILITY NUMBER:
197602669
ADMINISTRATOR:MICHELLE MAURERFACILITY TYPE:
740
ADDRESS:6156 HEDGEWALL DR.TELEPHONE:
(818) 879-9900
CITY:WESTLAKE VILLAGESTATE: CAZIP CODE:
91362
CAPACITY: 6CENSUS: 6DATE:
12/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Michelle Maurer and Robert MaralitTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a required annual visit. This annual had a specific emphasis on infection control practices. The LPA was greeted by two (2) staff and six (6) residents. The LPA spoke with Administrator Michelle Maurer over the phone and informed them of the reason for the visit.

The LPA toured the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 11:10 a.m., the LPA observed that the cleaning supplies were accessible, as the locking mechanism for the cabinet appeared to be inoperable. Staff were unable to fix the locking mechanism upon observation. Cleaning supplies were removed from under the sink upon observation. At 11:20 a.m., medication pill boxes were accessible in an unlocked kitchen drawer. At 11:25 a.m., knives and sharp objects were accessible in an unlocked cabinet. At 11:50 a.m., the LPA reminded staff of the items that needed to be secured, as knives and sharps were still accessible at 11:50 a.m. Staff stated that they understood.

BEDROOMS: Bedrooms were observed with appropriate furnishings, clean linens and sufficient lighting.

RESTROOMS: Restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Restrooms were stocked with soap and paper towels. Hand hygiene signs were posted in restrooms. Hot water temperature measured at 109 F.

COMMON SPACES: Living room and dining room furniture were observed to be in good condition. The fireplace is covered and inaccessible. All exits have functioning auditory devices. The LPA observed the required postings on the wall. The backyard has a covered area equipped with furniture for resident use. The side gate door was self-latching. No bodies of water noted. The attached garage was locked.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2022
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: LEISURE LIVING
FACILITY NUMBER: 197602669
VISIT DATE: 12/21/2022
NARRATIVE
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INFECTION CONTROL: There was a central entry point for symptom screening and temperature checks. Staff were wearing appropriate face coverings. Infection Control signs were observed throughout the facility. Facility has a sufficient supply of Personal Protection Equipment (PPE). The facility’s cleaning protocol was sufficient. The facility keeps record of staff and resident vaccinations. Staff are up to date regarding visitation protocol and vaccine requirements. The facility's procedures as it pertains to infection control were adequate.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.



Exit interview was conducted with Administrator Michelle Maurer over the phone, whom authorized staff to sign the report. A copy of the report, and Appeal Rights were issued.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/21/2022 12:12 PM - It Cannot Be Edited


Created By: Ashley Smith On 12/21/2022 at 11:45 AM
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: LEISURE LIVING
FACILITY NUMBER: 197602669

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

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 the knives were accessible in the kitchen cabinet, which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/22/2022
Plan of Correction
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The Administrator agreed to do the following:
1. Secure the items; inform CCL when this has taken place but no later than 12/21/2022, end of day
2. Remind staff of protocol for securing items that could pose a danger to residents. Communicate protocol no later than 12/22/2022, end of day
Type A
Section Cited
CCR
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 certain plants, gardening supplies, cleaning supplies and disinfectants.

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 the medications were accessible in the unlocked kitchen drawer and cleaning supplies were accessible under the kitchen sink, which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/22/2022
Plan of Correction
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The Administrator agreed to do the following:
1. Secure the items; inform CCL when this has taken place but no later than 12/21/2022, end of day
2. Fix/change locking mechanism under the sink no later than 12/22/2022
3. Remind staff of protocol for securing items that could pose a danger to residents (no later than 12/22/2022, end of day)
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:Ashley Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2022


LIC809 (FAS) - (06/04)
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