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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609306
Report Date: 10/17/2024
Date Signed: 10/17/2024 03:43:04 PM

Document Has Been Signed on 10/17/2024 03:43 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:ELAINE'S PLACEFACILITY NUMBER:
197609306
ADMINISTRATOR/
DIRECTOR:		BOTE, ELAINE PFACILITY TYPE:
740
ADDRESS:22745 DOLOROSA STREETTELEPHONE:
(818) 340-7769
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 6CENSUS: 6DATE:
10/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:22 AM
MET WITH:Elaine BoteTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 09:22AM. LPA met with Caregiver Norma Gregorio and reason for the visit was explained. Entrance interview conducted. Staff contacted Administrator Elaine Bote who arrived at 10:25AM.

Beginning at 09:24AM, the LPA, along with the caregiver 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:

BEDROOMS: There are six (6) single-occupancy resident bedrooms. At 09:27AM, LPA observed Bedroom #1 with two (2) out of four (4) light bulbs not working. Staff replaced the light bulbs during the visit. All client bedrooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

BATHROOMS: There are three (3) bathrooms, two (2) are in the hallway and one (1) is attached to Bedroom #3. All bathrooms were supplied with appropriate soap and paper towels. Between 09:30AM – 09:42AM, water temperatures were measured in bathrooms and measured within 128.2 degrees F – 138.7 degrees F, which is outside of the required range of 105 degrees F – 120 degrees F. Staff lowered water heater. At 12:01PM, LPA measured water temperature in bathroom #1 which measured at 135.0 degrees F. Administrator installed warning signs to label and properly identify hot water until the water heater can be repaired.

KITCHEN: At 10AM, LPA inspected the kitchen/food service area. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. At 10:09AM, LPA observed a spoiled cucumber, vegetable produce stored without bags or containers, a dented can of tomatoes, and opened and unrefrigerated jars of relish and jam. Staff discarded all items immediately and stored vegetable produce in bags. Knives, sharps, cleaning supplies, and disinfectants are stored inaccessible in a locked cabinet. Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ELAINE'S PLACE
FACILITY NUMBER: 197609306
VISIT DATE: 10/17/2024
NARRATIVE
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COMMON AREAS: These include the living room and dining area. Common areas were appropriately furnished and in good condition. Carbon monoxide detector was tested at 10:58AM and was operable. Smoke detectors were tested at 10:59AM. LPA observed the smoke detector in the living room not working. Staff attempted to fix the detector during the visit. Staff purchased and installed a new smoke detector which was tested at 03:09PM and was operable. LPA observed two (2) fire doors, one (1) to the hallway leading to resident bedrooms and the other one (1) to bedroom #6. Fire doors were not functioning properly as they had a door stopper by use of a rubber band on the handle which prevented the doors from closing when smoke detectors were tested. Administrator purchased a fire door holder that keeps the doors open during the day and is kept closed at night. Two (2) fire extinguishers were observed on a wall by the laundry room and in the kitchen area which were fully charged and last purchased 05/06/2024. Required posters were displayed throughout the common areas.

OUTDOOR AREA: The backyard has patio furniture and a covered area. No obstructions observed in the passageways. No bodies of water were observed.

MEDICATIONS: Medications review began at 10:17AM; medications are centrally stored and kept inaccessible in a locked kitchen cabinet. LPA reviewed medications for three (3) residents. LPA observed three (3) medications which were not logged on the centrally stored medication and destruction record. Staff immediately logged the medications.

RECORD REVIEW: LPA began record review at 11:06AM. LPA reviewed five (5) out of six (6) client files for documents including, but not limited to: appraisals, medical records, admissions agreement, and consent forms. One (1) out of five (5) residents had an initialed but not signed and dated Admissions Agreement. Resident reviewed and signed the Admission Agreement at the time of the visit. LPA reviewed three (3) personnel files for documents including, but not limited to: personnel record (LIC 501), health assessments/screening (LIC 503), criminal record clearances (LIC 508), active first aid/CPR training, and appropriate training. LPA observed two (2) out of three (3) staff to have CPR but no First Aid training. First aid training was completed during the time of the visit.

Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
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Page: 2 of 11
Document Has Been Signed on 10/17/2024 03:43 PM - It Cannot Be Edited


Created By: Angela Barutyan On 10/17/2024 at 02:34 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: ELAINE'S PLACE
FACILITY NUMBER: 197609306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

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 in that two (2) fire doors failed to self-close and the smoke detector in the living room was not operable which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
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Staff purchased a new smoke detector and installed it during the visit. Administrator purchased fire door holders during visit. POC is cleared.
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 in that water temperatures in resident bathrooms measured above 128.2 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
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Administrator lowered water temperature during visit. Administrator installed warning signs during visit to label and properly identify hot water until the water heater can be repaired. Administrator will send a seven day water log to CCL by 10/25/2024.
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:Kristin Heffernan
LICENSING EVALUATOR NAME:Angela Barutyan
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


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Document Has Been Signed on 10/17/2024 03:43 PM - It Cannot Be Edited


Created By: Angela Barutyan On 10/17/2024 at 02:34 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: ELAINE'S PLACE
FACILITY NUMBER: 197609306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(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 in that two (2) staff did not have first aid training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
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Staff completed first aid training during visit. POC is cleared.
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

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 in that three (3) medications were not logged on the centrally stored medication and destruction record which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
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Staff logged all medications during the visit. POC is cleared.
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:Kristin Heffernan
LICENSING EVALUATOR NAME:Angela Barutyan
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/17/2024 03:43 PM - It Cannot Be Edited


Created By: Angela Barutyan On 10/17/2024 at 02:34 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: ELAINE'S PLACE
FACILITY NUMBER: 197609306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

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 in that five (5) food items were not of good quality or stored properly which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2024
Plan of Correction
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Food items discarded during visit. POC cleared.
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:Kristin Heffernan
LICENSING EVALUATOR NAME:Angela Barutyan
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


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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: ELAINE'S PLACE
FACILITY NUMBER: 197609306
VISIT DATE: 10/17/2024
NARRATIVE
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INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices. The facility’s policies and procedures as it pertains to infection control are adequate. LPA was unable to review the emergency disaster plan and emergency disaster drills as the requested files were not kept on site.

INTERVIEWS: During today’s visit, LPA interviewed three (3) residents and three (3) staff.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Civil penalty was issued in the amount of $500. Administrator was informed that failure to correct deficiencies may result in additional civil penalties.

Exit interview conducted. The report was reviewed, and a copy of the appeal rights and report were provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
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