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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609500
Report Date: 03/16/2022
Date Signed: 03/16/2022 04:24:03 PM

Document Has Been Signed on 03/16/2022 04:24 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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:DEVONSHIRE ELDERLY CAREFACILITY NUMBER:
197609500
ADMINISTRATOR:BANGASH, FARAHFACILITY TYPE:
740
ADDRESS:17441 DEVONSHIRE STREETTELEPHONE:
(310) 955-0674
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 6CENSUS: 6DATE:
03/16/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Maria BangashTIME COMPLETED:
04:40 PM
NARRATIVE
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On 03/16/2022 Licensing Program Analyst (LPAs) Joscelyn Martinez, Melissa Ruiz and Long-Term Care Ombudsman Velvet Tabb arrived at the facility mentioned above for an unannounced annual continuation. Upon arrival LPAs and Ombudsman were greeted by staff Maria Bangash. This continued annual is focused on physical plant and health and safety.

A physical tour was conducted at 9:45 a.m and observed the following: Infection control: Covid-19 infection control signage were observed outside of the facility. Proper signage was also observed inside in the common areas. Upon entrance, staff took LPAs’ temperature and was asked to sign-in the visitor’s log. Food Inspection/Kitchen: LPAs observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Food storage and preparation areas were dirty and need immediate cleaning. All three (3) refrigerators in the facility were observed to have food stains, crumbs, and old liquid spills from frozen meats. Kitchen cabinets are in disrepair. LPAs observer water damage underneath the sink. Garbage cans did not have a tight-fitting lid in the kitchen. Sharps and some medications were centrally stored in a locked area. LPAs observed two plastic containers of medication accessible to residents inside the kitchen cabinet. Smoke detectors/carbon monoxide are located throughout the facility and are hardwired. Fire alarm and carbon monoxide alarm were tested at 12:07 p.m and appear to be functional. Fire extinguishers was observed in the facility with a purchase date of 02/22/22.

Continue on 809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2022
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: DEVONSHIRE ELDERLY CARE
FACILITY NUMBER: 197609500
VISIT DATE: 03/16/2022
NARRATIVE
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Common Areas: All common areas were observed to be cleaned and properly furnished. Facility maintains a comfortable temperature of 71.0 F. The facility does not have a working telephone. LPA Martinez attempted using the phone, but the phone indicated “no line”. LPA Martinez observed cleaning chemical in the living room closet and accessible to residents. Facility has many cracks throughout the walls which need repair. Resident rooms: There are eight (8) rooms which of three (3) are designated for staff use. All bedrooms were toured and were properly furnished and have appropriate bedding and linens. One of the shared bedrooms had a strong urine smell. This same bedroom also had an outlet with no cover and an exposed wire. Bathrooms: There are five and a half (5 1/2) bathrooms which of three (3) are for residents. The hot water temperature measured at 142.7 degrees Fahrenheit. One of the bathrooms did not have a trash can with a tight-fitting lid and did not contain a non-skid mat. Cleaning solution was observed inside the bathroom drawer and accessible to residents. This same restroom has a broken screen on the window that leads to the front of the house. Outside areas: LPAs toured the outside area of the facility. There is a separate unit which contains three (3) different rooms. These rooms are being used for Airbnb. The Airbnb guest have access to the house and the shared laundry area. There is an additional storage that contains the washer and dryer along with tools and chemicals. This unit is not locked and accessible to residents. LPAs observed appropriate outdoor furniture, with a covered shaded area for residents. There is an empty jacuzzi on the side of the house that is not being used.

Currently there is only one staff available to work in the facility. Staff members Maria stated that all of the other staff members are out of the country and do not have a current return date. LPAs reminded Maria that if she is the only staff available, she cannot leave the facility and needs to hire additional staff immediately. Citations will be addressed in a complaint visit done concurrently with today’s annual report.

Per California code Title 22 regulations issued. See 809Ds attached to this report. Report signed and delivered. Exit interview conducted. Appeal Right Issued.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
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Document Has Been Signed on 03/16/2022 04:24 PM - It Cannot Be Edited


Created By: Joscelyn Martinez On 03/16/2022 at 02:51 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: DEVONSHIRE ELDERLY CARE
FACILITY NUMBER: 197609500

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(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 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Water temperature meaured at 142.7 degree F.
Deficient Practice Statement
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Based on water temperature measurement, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2022
Plan of Correction
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Licensee will need to submit daily water temperature log for 3 weeks and adjust the hot water temperature to meet regulations by the POC due date.
Type A
Section Cited
CCR
87311
All facilities shall have telephone service on the premise

This requirement is not met as evidenced by:
LPA Martinez attempted to dial out using the land line but was not operational. Phone monitor displayed "No Line"
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2022
Plan of Correction
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Licensee is to add a working telephone to the facility that can be used by residents. Proof of installed land line should be email with facility phone number.
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/16/2022 04:24 PM - It Cannot Be Edited


Created By: Joscelyn Martinez On 03/16/2022 at 03:09 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: DEVONSHIRE ELDERLY CARE
FACILITY NUMBER: 197609500

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)
Non-skid mats or strips shall be used in all bathtubs and showers.

This requirement is not met as evidenced by:

One out of three bathrooms did not have a non-skid mat.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/20/2022
Plan of Correction
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Licensee is to purchase a non-skid mat for restroom place inside shower by the POC due date.
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022


LIC809 (FAS) - (06/04)
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