197606220-8-23-2024-31-AS-NRED-D8EQZ4-20240823123606

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606220
Report Date: 08/23/2024
Date Signed: 08/23/2024 12:36:35 PM

Document Has Been Signed on 08/23/2024 12:36 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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	WOODLAND WEST HOMES III		FACILITY NUMBER:	197606220
ADMINISTRATOR/ DIRECTOR:	EVANGELIA ANASTASI		FACILITY TYPE:	740
ADDRESS:	22537 MARLIN PLACE		TELEPHONE:	(818) 594-7294
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY: 6		CENSUS: 4	DATE:	08/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:05 AM
MET WITH:	Remedios Oster		TIME VISIT/ INSPECTION COMPLETED:	12:45 PM

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At approximately 9:05 a.m. on 08/23/24, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and disclosed the reason for the visit.

The facility was last visited on 03/22/23 for a complaint visit. It is a single story building with seven (07) bedrooms, three (03) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents. The facility serves residents with dementia. Approved hospice waivers for six (06). Surveillance cameras are located in common and exterior areas.

The front driveway was gated and unlocked. Shaded seating was available at the front. A ramp in good condition led up to the front entrance. Inside main entrance, LPA observed postings for facility sketch, administrator certificate, emergency disaster plan, rights of resident councils, COVID precautions, confidential complaint contacts, ombudsman contacts, and signs stating “No Smoking – Oxygen in use”. A screening station contained a visitor log and sanitizer.

Walls, floors, windows, screens, and blinds were clean and in good repair. At 9:15 a.m. LPA measured the room temperature to be 76 degrees Fahrenheit. Two (02) residents were observed in the living room watching television. The living room also contained furniture in good condition. Night lights were present in hallways. Two (02) hallway closets contained adequate supplies of fresh linens and extra hygiene supplies.

LPA observed an adequate supply of perishable and non-perishable foods in the kitchen and the garage. The stove and the hood were clean. Appliances were in good condition. Sharps were locked below the counter top. Cleaning solutions were locked in the laundry area. Medications and confidential files were locked in the office area. A washing machine and dryer were located near the kitchen. Both were in working order. At 9:35 a.m. LPA observed three (03) fully charged fire extinguishers throughout the home. All were last inspected on 06/04/24.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024

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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WOODLAND WEST HOMES III	FACILITY NUMBER: 197606220
	VISIT DATE: 08/23/2024

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The facility has seven (07) bedrooms. One (01) bedroom is designated as a staff room. The staff room was occupied and free of hazards. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition.

The facility has three (03) bathrooms. One (01) bathroom is private and two (02) are shared. All bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, commodes, and a non-skid mat in the shower. At approximately 9:50 a.m. LPA measured the water temperature in the front, shared bathroom to be 107.2 degrees Fahrenheit.

LPA observed a covered patio area in the rear of the facility. The patio contained furniture in good condition. The back yard was maintained and contained gardened areas and a locked storage shed.

Two (02) out of two (02) emergency exit paths were free from obstructions. Exit gates were unlocked with self-closing latches. Auditory alarms were functioning. At approximately 10:10 a.m., smoke and carbon monoxide detectors were tested and operational. At 10:20 a.m. the house telephone was called and deemed functional. The garage was accessible and contained extra supplies and perishable food.

At 10:30 a.m. LPA conducted a records review of resident and personnel files. All files were complete and available for audit.

During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed.

Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024

LIC809 (FAS) - (06/04)

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