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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609856
Report Date: 10/23/2024
Date Signed: 10/25/2024 04:52:19 PM

Document Has Been Signed on 10/25/2024 04:52 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:WESTFIELD SENIOR LIVINGFACILITY NUMBER:
197609856
ADMINISTRATOR/
DIRECTOR:		BALASANYAN, MARIAMFACILITY TYPE:
740
ADDRESS:7633 MASON AVETELEPHONE:
(818) 384-1134
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 6CENSUS: 4DATE:
10/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:06 AM
MET WITH:Armine Kiseleva- DesigneeTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an annual required visit and inspection of the facility. LPA was greeted by staff Armine Kiseleva and was advised for the reason of the visit. At 10AM Mariam Balasanyan who is the administrator met with LPA, explained the reason for the visit.

At 9:30 AM, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are operational that are located each bedroom, the hallway and kitchen. There are carbon monoxide detectors that functions properly. The fire extinguisher is in the dining room, bedrooms and hallway. The charge date is 9/25/2024. During the visit the facility is at 73 degrees Fahrenheit. The facility is fire cleared for six (06) non-ambulatory residents; hospice waiver six (6).

Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked drawerin the kitchen. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Cleaning supplies, pesticides or toxic cleaning supplies were stored locked away in the kitchen. During the tour, LPA found over-the-counter medication in an unlocked drawer in the kitchen and accessible to residents. Deficiencies will be issued in LIC 809-D.

Bedrooms: There were six (6) bedrooms designated for residents' use. Bedroom #1, bedroom #2, bedroom #3 (vacant), bedroom #4 (vacant), bedroom #5 and bedroom #6 are for private used, all of the bedrooms that are used by residents were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. During physical plant tour LPA noticed PRN, medications and supplements were seen in their residents bedrooms, deficiencies will be cited on LIC 809-D.
Continue to LIC 809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: WESTFIELD SENIOR LIVING
FACILITY NUMBER: 197609856
VISIT DATE: 10/23/2024
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Bathrooms: There are two (2) bathroom designated for residents' use. The bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 119.8 degrees Fahrenheit for bathroom #1 located in the hallway beside room #1. Bathroom #2 is inside bedroom #3. Hot water temperature was measured at 119.7 degrees Fahrenheit. There was enough clean linen available in the cabinets in the hallway.

Common Areas: LPA toured all common areas of the facility. These included the living room and dining area for residents. The common areas were properly furnished. Residents dining table fits enough for six (6). LPA observed common areas to be very clean and tidy. LPA observed the floors to be in very good condition. No obstructions and or tripping hazards throughout the facility. Furniture in common area was observed to be in good repair. There are no issues with Fire Clearance.

Infection control: Facility mitigation plan to make sure licensee was following current infection control recommendations. LPA obtain a copy and reviewed the infection control plan during this visit.

Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The facility does not have a swimming pool or body of water. Facility has no garage, but just a car port.

Laundry service: There is enough linen available to change weekly or more if need. Cleaning supplies are being stored in a unlocked cabinet in the laundry area located in the backyard. Cleaning supplies were also seen on the floor that was kept unlock that is accessible to the residents. Deficiency will be cited on LIC 809-D.

Staff Files: LPA conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Office space is in the living room. Records were checked for expired or missing certificates and clearances: LPA conducted a file review of staff for criminal record clearances and current First Aid. The administrator file was reviewed for current first aid, fingerprint clearance, administrator certificate, and HIV/AIDS and TB training.

Continue to LIC 809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
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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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: WESTFIELD SENIOR LIVING
FACILITY NUMBER: 197609856
VISIT DATE: 10/23/2024
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Medications are in a centrally stored but not in a locked place, LPA found staff medication, residents PRN, medications, and supplements in the living room and the bedrooms of the residents. Medications including over-the-counter medicines; medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been not been logged in the medications log with proper documentation from the clients’ doctor. Proper medication dispensing instruction are followed and checked for contamination. First-aid has all proper items and is current.

Resident records were reviewed for requirements and legibility: Planned activities are offered. LPA reviewed all of the resident files and is complete.

Facility is NOT within CA code of Regulations Title 22 or Health and Safety Code. Deficiencies were found, this will be cited on LIC 809-D. exit interview conducted, copy of report has been issued and discussed.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 10/25/2024 04:52 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 10/23/2024 at 12:59 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: 10/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
Storage Space
(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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 cleaning supplies, aerosols, scissors, lighter, and razors were accessible to residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2024
Plan of Correction
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Licensee needs to ensure any hazardous items should be lock and inaccessible to residents.
Type A
Section Cited
HSC
1569.695(a)(7)(E)


This requirement is not met as evidenced by:
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (7) Procedures that address, but are not limited to, all of the following: (E) Storage and preservation of medications, including the storage of medications that require refrigeration.

Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 over the counter medication, PRN and staff medication was kept unlock in the refrigerator which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2024
Plan of Correction
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Licensee needs to purchase a lockbox for the refrigerator.
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024


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Document Has Been Signed on 10/25/2024 04:52 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 10/23/2024 at 01:12 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: 10/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)


This requirement is not met as evidenced by: This requirement is not met as evidenced by: 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.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 residents medications, suppliments and over the counter medications were not locked and was accessible to residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2024
Plan of Correction
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Administrator needs to lock all rx, PRN, and supplements.
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/25/2024 04:52 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 10/23/2024 at 01:15 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: 10/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
874659(c)(3)


This requirement is not met as evidenced by: A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 count out of 1 PRN medications were not documents in CSMDR which poses/posed a potential health, safet
POC Due Date: 11/06/2024
Plan of Correction
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All supplements and PRN medications needs to be documented in CSMDR.
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024


LIC809 (FAS) - (06/04)
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