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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609856
Report Date: 10/21/2022
Date Signed: 10/21/2022 02:40:55 PM

Document Has Been Signed on 10/21/2022 02:40 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:WESTFIELD SENIOR LIVINGFACILITY NUMBER:
197609856
ADMINISTRATOR:BALASANYAN, MARIAMFACILITY TYPE:
740
ADDRESS:7633 MASON AVETELEPHONE:
(818) 384-1134
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 6CENSUS: 5DATE:
10/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Alina Abraamyan, Anahit GrigorianTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with staff, Alina Abraamyan and Anahit Grigorian. They were advised of the reason for the visit.

At approximately 12:00pm, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are battery operated. The carbon monoxide detector functions properly. There are two fire extinguishers thar are located by the kitchen and in the hallway. Although purchased on 9/13/19, both fire extinguishers are fully charged.

Kitchen: 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 one of the kitchen cabinets.

Bedrooms: There were six (6) bedrooms designated for residents' use. All bedrooms were properly furnished with appropriate beddings and linens with sufficient lighting.

Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 135 degrees Fahrenheit.

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. The internal temperature was maintained comfortably at 75 degrees.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2022
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: WESTFIELD SENIOR LIVING
FACILITY NUMBER: 197609856
VISIT DATE: 10/21/2022
NARRATIVE
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Surrounding Grounds: Entry/exits were free of obstruction. The outdoor area was free of hazards. The laundry area

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.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiencies were cited (refer to LIC 809-D).

Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/21/2022 02:40 PM - It Cannot Be Edited


Created By: Michael Cava On 10/21/2022 at 12:28 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: WESTFIELD SENIOR LIVING
FACILITY NUMBER: 197609856

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2022

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: During the physical plant inspection, the the hot water taken at the bathroom sink was measured at 135 degrees.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in one out of two bathrooms where the hot water temperature was taken, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2022
Plan of Correction
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Prior to the end of the visit, staff adjusted the hot water to insure it measures between 105-120 degrees. No further correction needed at this time.
Type A
Section Cited
CCR
87309(a)
Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by: During the physical plant inspection, LPA observed air freshener in both bathrooms that are used by the residents.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in two out of two bathrooms that were inspected by the LPA, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2022
Plan of Correction
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During the inspection, staff removed the air fresheners from both bathrooms and stored them in a locked cabinet underneath the kitchen sink.
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:Michael Cava
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2022


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