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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609675
Report Date: 04/22/2024
Date Signed: 04/22/2024 03:39:17 PM

Document Has Been Signed on 04/22/2024 03:39 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:HIGHLANDS MANOR INCFACILITY NUMBER:
197609675
ADMINISTRATOR/
DIRECTOR:
LEVIN, RUSLANFACILITY TYPE:
740
ADDRESS:9811 BELMAR AVETELEPHONE:
(747) 206-5436
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 6CENSUS: 6DATE:
04/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:RUSLAN LEVIN- AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with staff and explained the reason for the visit. Administrator, Ruslan Levin arrived shortly after. At approximately 10:45 am, with the assistance of staff, LPA took a tour of the physical plant.
Kitchen: Required postings were observed in the kitchen. The fire extinguisher is located in the kitchen with purchase date 4/22/24. The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in the hallway cabinet. Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility and were tested and observed to be operational. Bedrooms: There were six (6) bedrooms designated for residents' use. All bedrooms are designated for private use. All six (6) bedrooms, in use by residents, were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are five (5) bathrooms designated for residents' use. All bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathrooms sink at 111.7, 115.0, and 116.3 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathroom during the inspection. Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The garage: Laundry area is located in an attached garage and kept locked and inaccessible to residents.
Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.
Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms. Medications: Medication and Medication Records were review for proper documentation.LPA could not complete an accurate medication count due to incomplete medication forms. Exit interview conducted, citation issued and copy of this report delivered.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE: DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2024
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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Document Has Been Signed on 04/22/2024 03:39 PM - It Cannot Be Edited


Created By: Mariana Agban On 04/22/2024 at 02:49 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: HIGHLANDS MANOR INC

FACILITY NUMBER: 197609675

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 04/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(5)

Incidential Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on medications review and interview, the licensee did not comply with the section cited above, as the LPA could not complete an accurate medication count, which poses a potential health and safety risk to residents in care.
POC Due Date: 04/29/2024
Plan of Correction
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Administrator has agreed to conducted medication audit for all the residents and submit complete medications forms to LPA by the POC 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:Eva Miller
LICENSING EVALUATOR NAME:Mariana Agban
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2024


LIC809 (FAS) - (06/04)
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