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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608280
Report Date: 09/07/2021
Date Signed: 09/07/2021 06:07:35 PM

Document Has Been Signed on 09/07/2021 06:07 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:FOUR SEASONS ASSISTED LIVING CENTER LLCFACILITY NUMBER:
197608280
ADMINISTRATOR:MELISSA CHRISTOPHERFACILITY TYPE:
740
ADDRESS:12120 CHANDLER BLVDTELEPHONE:
(818) 487-0770
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91607
CAPACITY: 49CENSUS: 30DATE:
09/07/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Melissa ChristopherTIME COMPLETED:
06:00 PM
NARRATIVE
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At 8:30am, Licensing Program Analysts (LPAs) Sandra Urena and Salia Walker conducted an unannounced Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint control # 29-AS-20210902165549). Upon arrival, LPAs were greeted at the door by Activities Director Ulka Sanghaui. The LPAs met with Administrator Melissa Christopher at approximately 09:00 a.m. and explained the reason for the visit.

During today’s visit, the LPAs reviewed files for twenty (20) out of thirty (30) residents between 08:30 a.m. and 04:00 p.m. Resident files were reviewed for admission agreements, medical assessments, appraisals, consent forms and medication records. Upon review of residents' files, it was observed that twenty (20) out of twenty (20) residents did not have an LIC 603A Re-appraisal nor an updated LIC 625. Therefore, based on records reviewed 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 conducted. Signatures obtained. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2021
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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Document Has Been Signed on 09/07/2021 06:07 PM - It Cannot Be Edited


Created By: Sandra Urena On 09/07/2021 at 04:43 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: FOUR SEASONS ASSISTED LIVING CENTER LLC
FACILITY NUMBER: 197608280

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/07/2021
Section Cited
CCR
87463(a)

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(a)The pre-admission appraisal shall be updated.. as frequently as necessary.. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition..
This requirement is not met as evidenced by:



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The Licensee has agreed to do the following:

1. Submit proof of all residents’ documents LIC 603A/LIC 625 by 09/17/2021.
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Based on observation, the licensee did not comply with the section cited above, as twenty (20) out of twenty (20) residents’ files did not have a reappraisal, which poses an immediate health and safety risk to residents in care.
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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:Sandra Urena
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2021


LIC809 (FAS) - (06/04)
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