197609824-8-27-2024-29-AS-TBYE-D8JST6-20240827140901

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609824
Report Date: 08/27/2024
Date Signed: 08/27/2024 02:10:47 PM

Document Has Been Signed on 08/27/2024 02:10 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:	ASHLEY'S GARDEN ELDERLY CARE		FACILITY NUMBER:	197609824
ADMINISTRATOR/ DIRECTOR:	OSBORN, ANNIE		FACILITY TYPE:	740
ADDRESS:	7930 RHODES AVE		TELEPHONE:	(818) 642-0907
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY: 6		CENSUS: 5	DATE:	08/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:04 AM
MET WITH:	Annie Osborn		TIME VISIT/ INSPECTION COMPLETED:	02:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:04 AM. LPA met with facility staff who contacted the facility administrator Annie Osborn via telephone call. Facility administrator arrived to the facility at 09:20 AM Entrance interview conducted and the reason for the visit was explained. Beginning at 09:20 AM, the LPA, along with facility administrator 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: KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) days perishable and two (2) days non-perishable food. LPA observed a secured drawer to contain knives and other sharp objects. The LPA observed the fire extinguisher to be fully charged and purchased on 05/25/2024. Cleaning chemicals are stored securely under the kitchen sink. BEDROOMS: There are four (4) bedrooms in the facility; three (3) are designated for resident use and one (1) is designated as a staff room. All resident rooms are designated as dual occupancy rooms. LPA and facility administrator toured all three (3) resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedroom number three (#3) contains a direct exit to the backyard. An auditory alarm was observed and was functional at the time of the visit. The staff room is secured and inaccessible to residents. Report Continued on LIC 809-C

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024

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 4

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: ASHLEY'S GARDEN ELDERLY CARE	FACILITY NUMBER: 197609824
	VISIT DATE: 08/27/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

BATHROOMS: There are two (2) bathrooms at the facility. Both bathrooms were observed to be clean and in good repair and all were equipped with nonskid surfaces. Grab bars were observed in all showers and near all toilets, all were properly secured. The water temperature was measured between 117.1 and 117.5 degrees Fahrenheit, which is in compliance with regulation.

COMMON AREAS: This includes the living room and dining room. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contains an appropriately screened fireplace and board games for resident use. Smoke detectors and carbon monoxide detectors were tested at 09:43 a.m. and were functional at the time of the visit. The dining room was observed to be clean and contains adequate seating for resident use. LPA observed adequate amounts of emergency food stored in a pantry. The facility’s first aid kit was inspected and contained all required supplies. The first aid kit contained an unsecured box of prescription Ipratropium Bromid 0.02% solution.

OUTDOOR SPACE/GARAGE: The facility has one (1) emergency exit gate located at the front entrance to the property, LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. The garage was observed to be secured and contains an extra refrigerator, a washer and dryer, cleaning chemicals, and extra care supplies. The garage contains adequate emergency water supplies as well as an emergency generator.

RECORD REVIEW: Record review began at 10:10 a.m. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, TB tests, consent forms, and personal rights. Three (3) staff files were reviewed. All staff files contained the required documents and trainings. Five (5) resident files were reviewed. All resident files reviewed contained all required documentation. No deficiencies were observed during record review.

MEDICATION REVIEW: Medication review began at 11:23 a.m. Medications are stored centrally and securely in a cabinet in the kitchen. Medications for two (2) residents were observed. All medications reviewed were documented properly on their centrally stored medication and destruction record sheet. No deficiencies were observed during medication review. Report Continued on LIC 809-C

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: ASHLEY'S GARDEN ELDERLY CARE	FACILITY NUMBER: 197609824
	VISIT DATE: 08/27/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the
facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Last emergency disaster drill was conducted on 07/23/2024. The facility’s emergency disaster plan is up to date and adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated quarterly.

INTERVIEWS: LPA interviewed two (2) staff and two (2) residents. All residents interviewed stated that the food was of good quality and is provided in sufficient amounts. All residents stated that staff treat them well and are attentive to their needs. No residents interviewed had concerns with the facility. Both staff members interviewed were knowledgeable on their roles and responsibilities, resident rights, the different forms of abuse and the appropriate reporting procedures for suspected abuse.

During today’s visit LPA obtained a copy of the facility’s updated LIC500, resident roster, and liability insurance.

The Pursuant to Title 22 of the CA Code of Regulations, and the Health and Safety Code, the following deficiency was cited (refer to LIC 809-D):

Citation was issued. Exit interview was conducted. today's report, and appeal rights were reviewed and issued.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 08/27/2024 02:10 PM - It Cannot Be Edited

Created By: Trevor Byrne On 08/27/2024 at 01:51 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ASHLEY'S GARDEN ELDERLY CARE	FACILITY NUMBER: 197609824
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(2)

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as expired perscription Ipratropium Bromid 0.02% Solution was observed unsecured in the facility's first aid box which posed a potential health risk to persons in care.
	POC Due Date: 08/27/2024
	Plan of Correction
1 2 3 4	Medication was removed and disposed of at the time of visit. POC cleared.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Kasandra Lopez

LICENSING EVALUATOR NAME:

Trevor Byrne

LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4