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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610163
Report Date: 09/26/2024
Date Signed: 09/26/2024 03:46:02 PM

Document Has Been Signed on 09/26/2024 03:46 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:A & V SENIOR CAREFACILITY NUMBER:
197610163
ADMINISTRATOR/
DIRECTOR:		GONZALEZ, LORENAFACILITY TYPE:
740
ADDRESS:14928 HIAWATHA STREETTELEPHONE:
(818) 921-0589
CITY:MISSION HILLSSTATE: CAZIP CODE:
91345
CAPACITY: 6CENSUS: 3DATE:
09/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:32 PM
MET WITH:Florence Peregrino - DesigneeTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Licensing Program Analysts (LPAs) Gary Tan and Angelica Segovie conducted an unannounced Required One (1) year visit at this facility. LPA met with Florence Peregrino, facility administrator designee and explained the reason for the visit.

There is only one entrance being utilized at the facility, there are required poster posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Infection Control and Mitigation plan. The screen door however has a broken handle.

Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside and inside. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room. At 12:52 PM, tour of the physical plant was conducted with the staff. This facility is a single storey house and has five (5) bedrooms and two (2) bathrooms currently occupying three (3) residents. One (1) bedroom is designated for staff use. The facility is fire cleared for six (6) ambulatory residents, four (4) of which may be ambulatory and one (1) maybe bedridden in Room #5, hospice waiver for six (6) residents.

Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, the following was noted:
Living and dining room furniture were also checked. The living room is neat and clean along with the dining room. The facility maintains a comfortable temperature at 74°F. The smoke detector is hardwired, tested and observed to be operational. There are two (2) fire extinguishers located in the kitchen. Both extinguishers are observed to be full and last checked on 06/03/24. There is carbon monoxide detector installed at the facility. (continued on LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: A & V SENIOR CARE
FACILITY NUMBER: 197610163
VISIT DATE: 09/26/2024
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The backyard of the facility has outdoor furniture, with a covered shaded area for clients. There is no body of water in the facility. There is a shed located in the other side of the backyard currently being used as an old equipment storage and inaccessible to residents.

Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Cleaning supplies, laundry detergents, pesticides or toxins were stored in the kitchen cabinet and observed to be locked and inaccessible to residents. All sharps and knives were also observed to be locked in a kitchen cabinet. At this time, there is no laundry or dryer machine at the facility. Per the designee, it was taken a week ago and no delivery yet to date.

The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit to non-private rooms. Clients have sufficient amounts of personal hygiene product which is provided by the licensee. Staff Rooms: Staff room was observed to be locked. No medications are observed in the staff room.

The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. The hot water temperature measured at a range of 108.2°F to 117.3°F. Towels and washcloths are not shared. There is enough clean linen available in stock at the cabinet.



Medications: LPA observed medication in the kitchen cabinet to be locked and inaccessible to residents. Medications are listed on the centrally stored medication and destruction record. There are two (2) complete first aid kits located in the medication cabinet.

Client and Staff records all residents and staff present records were reviewed. Residents and staff record appeared to be complete and updated.

Disaster drill was last conducted on 08/15/24. Required posting are observed to be complete and current and displayed properly at the facility.

Citation issued. Appeal rights discussed and given. Exit interview conducted and copy of this report issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/26/2024 03:46 PM - It Cannot Be Edited


Created By: Jose Gary Tan On 09/26/2024 at 01:20 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: A & V SENIOR CARE
FACILITY NUMBER: 197610163

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
(a) 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 visittors

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs' observation, the licensee did not comply with the section cited above wherein the screen on the main door handle was broken which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/03/2024
Plan of Correction
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The administrator agreed to replace the broken handle or the door itself and will submit proof of correction on or before the POC date.
Type B
Section Cited
CCR
87303(g)(2)
(2) Make at least one machine available for use by the residents who are able and who desire to do their own personal laundry. This machine shall be maintained in good repair. Equipment in good repair shall be provided to residents who are capable and desire to iron their own clothes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above as there is no laundry machine in the facility, it poses/posed a potential personal rights risk to persons in care.
POC Due Date: 10/03/2024
Plan of Correction
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The administrator agreed to hasten the delivery of the new laundry and dryer machine and install it immediately. Administrator agreed to send proof of working laundry machine and send it to CCL on or befofe the POC date.
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:Troy Agard
LICENSING EVALUATOR NAME:Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024


LIC809 (FAS) - (06/04)
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