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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609786
Report Date: 10/30/2024
Date Signed: 10/30/2024 05:53:19 PM

Document Has Been Signed on 10/30/2024 05:53 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:WOODLAND HILLS RETIREMENT HOMEFACILITY NUMBER:
197609786
ADMINISTRATOR/
DIRECTOR:		KALISTRATOV, SERGUEIFACILITY TYPE:
740
ADDRESS:24301 OXNARD STTELEPHONE:
(818) 564-4381
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 6CENSUS: 6DATE:
10/30/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Serguei KalistratovTIME VISIT/
INSPECTION COMPLETED:
06:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angela Barutyan conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control #29-AS-20241029131721). The purpose of the visit is to issue citations for deficiencies observed during the initial complaint investigation.

During the visit on 10/30/2024, LPA conducted a medication review at 11:24AM. LPA observed PRN medications for three (3) residents which were not properly logged. Staff were unable to confirm which medication packs the PRN medications were administered from as the Rx number, date filled, and date expired were not logged. LPA also observed medications prepped and stored in medication pill boxes three (3) days in advance. Staff were unable to confirm which medication packs the medications in the pill boxes were prepped from as the medication packs had been thrown away. Review of the facility’s LIC 500 Personnel Report documented two (2) staff members without a criminal record clearance.

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. Civil penalties were issued in the amount of $1000. Failure to correct the deficiencies may result in additional civil penalties.

Licensee was unable to stay for the duration of the visit and designated staff Arystanbek Yeshibayev to sign the report.

Exit interview was conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 10/30/2024 05:53 PM - It Cannot Be Edited


Created By: Angela Barutyan On 10/30/2024 at 04:45 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: 10/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2024
Section Cited
CCR
87355(e)

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
This requirement is not met as evidenced by:
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Licensee stated that the two staff are associated to his other facility and will transfer their criminal record clearance by today. Licensee will submit proof to CCL by 10/31/2024.
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Based on record review, the licensee did not comply with the section cited above as two employees were observed without a criminal record clearance which poses an immediate health, safety, or personal rights risk to persons in care.
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Type A
10/31/2024
Section Cited
CCR87465(h)(5)

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87465 Incidental Medical and Dental Care (h)The following requirements shall apply to medications...: (5)Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
This requirement is not met as evidenced by:
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Licensee stated that they will conduct a meeting with all staff to discuss medication preparation and storage. Licensee will submit proof to CCL by 10/31/2024.
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Based on observation, the licensee did not comply with the section cited above as medications were stored in pill boxes three days in advance which poses an immediate health, safety, or personal rights risk to persons 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:Kristin Heffernan
LICENSING EVALUATOR NAME:Angela Barutyan
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/31/2024 09:56 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/31/2024 09:00 AM


Created By: Angela Barutyan On 10/30/2024 at 04:50 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WOODLAND HILLS RETIREMENT HOME
FACILITY NUMBER: 197609786

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/07/2024
Section Cited
CCR
87465(d)

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87465 Incidental Medical and Dental Care (d)If the resident is unable to determine his/her own need for a...PRN medication...facility staff...shall be permitted to assist the resident...provided all of the following requirements are met:
This requirement is not met as evidenced by:
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Licensee stated they will conduct training with staff to address PRN medication logging to ensure that Rx number, date filled, and date expired are logged. Licensee will submit proof to CCL by 11/07/2024.
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Based on medication review, the licensee did not comply with the section cited above as PRN medications for 3 residents were not properly logged which poses a potential health, safety, or personal rights risk to persons 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:Kristin Heffernan
LICENSING EVALUATOR NAME:Angela Barutyan
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2024


LIC809 (FAS) - (06/04)
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