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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603936
Report Date: 08/03/2022
Date Signed: 08/03/2022 01:23:39 PM

Document Has Been Signed on 08/03/2022 01:23 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:JUST LIKE HOMEFACILITY NUMBER:
197603936
ADMINISTRATOR:ALEXSANDRA VARTAPETOVAFACILITY TYPE:
740
ADDRESS:12521 KILLION STREETTELEPHONE:
(818) 769-9955
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY: 6CENSUS: 5DATE:
08/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Alexsandra VartapetovTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elsie Campos arrived unannounced to conduct a required annual visit. This annual had a specific emphasis on infection control practices. The LPA met with Administrator Alexsandra Vartapetova and explained 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. Kitchen drawer containing knives was unlocked with no accessible key at 10:00 a.m. Medications were observed unlocked in various kitchen drawers and cabinets at 10:03 a.m. Laundry room is located through the kitchen with access to a bathroom where cleaning supplies are kept. Laundry detergent, Clorox bleach, and cleaning supplies were observed unlocked at 10:05 a.m. All items were appropriately secured by the end of the visit. BEDROOMS: Bedrooms had appropriate furnishings, clean linens, and sufficient lighting. RESTROOMS: Resident restrooms were clean and sanitary with grab bars and non-skid surfaces. Administrator was reminded to post hand hygiene signs in all restrooms. COMMON SPACES: The facility maintained a temperature of 76 degrees. Living room and dining furniture were observed to be in good condition. Required postings were observed at the entrance. The LPA toured the outside area of the facility. The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There is a swimming pool on the premises, which the LPA observed to be unlocked at 10:28 a.m. The pool was locked upon observation. At 10:30 a.m., the LPA observed multiple screen doors in need of repairs, an obstructed outdoor walkway with an old recliner and accessible gardening shears located on the walkway wall. The recliner was appropriately removed, and the gardening shears were appropriately secured upon observation.

Continued on LIC 809-C

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2022
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 08/03/2022 01:23 PM - It Cannot Be Edited


Created By: Elsie Campos On 08/03/2022 at 11:09 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: JUST LIKE HOME
FACILITY NUMBER: 197603936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

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 staff was observed not wearing masks upon arrival to the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2022
Plan of Correction
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Administrator agreed to the following:
1. Re-train all staff on infection control and mask wearing, provide training docuemnts with staff signatures to CCL no later than 8/8/2022.
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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Elsie Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022


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Document Has Been Signed on 08/03/2022 01:23 PM - It Cannot Be Edited


Created By: Elsie Campos On 08/03/2022 at 11:27 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: JUST LIKE HOME
FACILITY NUMBER: 197603936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on obseevation, the licensee did not comply with the section cited above, as the exterior exit walkway was blocked, which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/03/2022
Plan of Correction
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The Administrator agreed to do the following:
1. Remove the recliner clearing the walkway. Plan of correction met at the time of the visit.
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 cleaning supplies and disinfectants were observed accessible to resident which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/03/2022
Plan of Correction
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The Administrator agreed to do the following:
1. Secure all items. Plan of correction met at the time of the visit.
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:Elsie Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022


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Document Has Been Signed on 08/03/2022 01:23 PM - It Cannot Be Edited


Created By: Elsie Campos On 08/03/2022 at 11:27 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: JUST LIKE HOME
FACILITY NUMBER: 197603936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 Resident medications were not secured and were accessible to other residents which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/04/2022
Plan of Correction
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The Adminstrator agreed to the following:
1. Secure all medications. Medications were secured at the time of visit. POC met.
Type A
Section Cited
CCR
87705(e)
Care of Persons with Dementia
(e) Swimming pools and other bodies of water shall be fenced and in compliance with state and local building codes.

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 swimming pool gate was unlocked at time of the visit which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/03/2022
Plan of Correction
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Adminsitrator agreed to do the following:
1. Ensured that the gate was locked upon observation.
Plan of Correction met. Zero Tolerance violation; a civil penalty was assessed during today's visit.
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:Elsie Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022


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Document Has Been Signed on 08/03/2022 01:23 PM - It Cannot Be Edited


Created By: Elsie Campos On 08/03/2022 at 11:27 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: JUST LIKE HOME
FACILITY NUMBER: 197603936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

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 in 3 sliding door window screens were observed to be in disrepair which poses a potential health and safety risk to persons in care.
POC Due Date: 08/10/2022
Plan of Correction
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The Adminstrator agreed to the following:
1. Repair the broken screens and provide proof to CCL no later than 8/10/2022.
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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Elsie Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022


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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: JUST LIKE HOME
FACILITY NUMBER: 197603936
VISIT DATE: 08/03/2022
NARRATIVE
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Infection Control: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. There is a centralized location with COVID-19 signs that promoted hand hygiene, physical distancing, and cough/sneeze etiquette. Staff did not conduct temperatures checks or sign in upon entry however, the Administrator was reminded that COVID-19 guidelines are still in place. Upon entry 1 staff was observed without a mask and Administrator was reminded that masking guidelines are still in place. There is sanitizer available for use throughout the facility. There is an adequate supply of Personal Protection Equipment (PPE), but the facility would like additional anti-gen tests, gloves and hand sanitizer. The facility’s cleaning protocol is sufficient. The facility can designate a single-person room to isolate persons if there is a confirmed case of COVID-19. The LPA requested to have staff updated regarding guidelines around visitation and vaccine requirements. The most recent Infection Control plan will be submitted to CCL by the due date. The Administrator continues to conduct testing, regardless of vaccination status. The licensee is reminded that any and all cases of COVID-19 are to be reported to licensing timely and to continue following COVID-19 guidelines.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

An exit interview was conducted, and Plan of Corrections were reviewed and developed with the Licensee. A copy of this report, LIC 809-D, and Appeal Rights were discussed and provided to Administrator, whose signature on this form confirm receipt of these documents.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
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