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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609856
Report Date: 11/18/2024
Date Signed: 11/22/2024 11:37:09 AM

Document Has Been Signed on 11/22/2024 11:37 AM - 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:
11/18/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:25 PM
MET WITH:Armine Kiseleva- DesigneeTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Leslie Ngo-Castaneda and Nadia Shahbazian met with facility designee Armine Kiseleva for a Plan Of Correction (POC) visit.

The purpose of the POC visit is to make sure deficiencies were corrected on reports issued on 10.23.2024

Entrance interview conducted.

At 12:45PM LPAs toured the home and requested the following:

-CCR 874659(c)(3) Incidental Medical and Dental Care Services:

POC: 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, safety.

POC date 10.8.2024: All supplements and PRN medications is documented in CSMDR.

For todays visit 11.18.2024, LPAs saw a repeat violation that was cleared on 10.23.2024. Therefore, an immediate civil penalty is issued for failure to correct the violation, and a new LIC 809-D is created with a new Plan of correction (POC) date. Administrator was contacted and LPA was informed that all required documents will be submitted promptly.

Exit interview conducted, appeal rights given and a copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
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 11/22/2024 11:37 AM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 11/18/2024 at 01:35 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: 11/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/19/2024
Section Cited
CCR
87309(a)(1)

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(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
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Licensee needs to ensure any hazardous items should be lock and inaccessible to residents.
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is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in 1 out of 1 aerosols, scissors, and lighter were accessible to residents which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type A
11/19/2024
Section Cited
HSC1569.695(a)(7)(E)

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(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
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Licensee needs to ensure PRN and/or OTC medications shoule be stored in a lockbox in the refrigerator.
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medications, including the storage of medications that require refrigeration. 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.
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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: 11/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/22/2024 11:37 AM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 11/18/2024 at 01:56 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: 11/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/02/2024
Section Cited
CCR
87303(a)

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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Licensee needs to ensure that R4 bedroom is free of other individuals belongings, only R4 can have their belongings inside.
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 This was observed were LPAs saw R4 bedroom has other individuals belongings in their bedroom which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
12/02/2024
Section Cited
CCR87506(a)

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The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
This requirement is not met as evidenced by:
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Administrator/Licensee shall do R4 complete files via email to LPA by:

POC 12.2.2024.
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Based on the LPAs observations and interviews the licensee/administrator did not ensure one out of four files to be available for licensing to review which poses a Potential Health, Safety or Personal Rights risks 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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2024


LIC809 (FAS) - (06/04)
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