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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609786
Report Date: 09/13/2022
Date Signed: 09/13/2022 04:36:18 PM

Document Has Been Signed on 09/13/2022 04:36 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:WOODLAND HILLS RETIREMENT HOMEFACILITY NUMBER:
197609786
ADMINISTRATOR:KALISTRATOV, SERGUEIFACILITY TYPE:
740
ADDRESS:24301 OXNARD STTELEPHONE:
(818) 564-4381
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 6CENSUS: 3DATE:
09/13/2022
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Irina Freid and Serguei KalistratovTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elsie Campos conducted an unannounced Case Management-Deficiencies inspection visit at the facility today due to deficiencies observed during the investigation of complaint control # 29-NP-20220222171126.

At 11:45 a.m. the LPA conducted a medication audit. The LPA audited medications for two out of three residents. Resident #1 (R1), Resident #2 (R2) had prescription medications and PRN medications; however, medication documentation log was inaccurate. The LPA observed that on the medication notes, staff indicated inaccurately medication prescription RX numbers, medication expiration dates, and issued dates did not match with the medications on hand. The LPA had a discussion with the Administrator addressing the Centrally Stored Medication Log and its requirements to be current and updated anytime medication enters the facility. The facility plans to have a full medication audit completed by their local pharmacy within the next three weeks.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 809-D). Exit interview conducted, today's reports and appeal rights were reviewed and issued via email.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2022
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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Document Has Been Signed on 09/13/2022 04:36 PM - It Cannot Be Edited


Created By: Elsie Campos On 09/13/2022 at 03:27 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: WOODLAND HILLS RETIREMENT HOME
FACILITY NUMBER: 197609786

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/15/2022
Section Cited
CCR
87465(a)(4)

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87465(a)(4) Incidental Medical and Dental. The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
1. Schedule an in-service training with an outside agency within the next 48 hours and provide proof to CCL no later than 9/15/2022.
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Based on observation, the licensee did not comply in the section cited above for two out of three residents (R1, R2) which poses an immediate health and safety risk to residents in care. The Administrator agreed to the following:
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2. Host an in-service training with an outside agency around the self-administration of medications, specifically discussing all medication documentation and completing the Centrally Stored Medication and Destruction Record. Training and proof must be completed no later than 9/30/2022.

Type B
09/23/2022
Section Cited
CCR87465(h)(6)

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87465(h)(6) Incidental Medical and Dental Care: The following requirements shall apply to medications which are centrally stored: The licensee shall be responsible for assuring that a record of centrally stored presciption medications...is maintained…
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The Administrator agreed to do the following: 1. Host an in-service training with an outside agency around the self-administration of medications, specifically discussing all medication documentation and completing the Centrally Stored Medication and Destruction Record.
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This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above, as two (2) out of three (3) resident files did not contain properly completed centrally stored medication logs, which poses a potential health, and safety risk to persons in care.
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2. Update the Centrally Stored Medication Log for all residents and provide proof to CCL no later than 9/23/2022.
Training and proof must be completed no later than 9/30/2022.


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:Elsie Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2022


LIC809 (FAS) - (06/04)
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