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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801657
Report Date: 09/13/2024
Date Signed: 09/13/2024 03:08:44 PM

Document Has Been Signed on 09/13/2024 03:08 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:LA SALLE CARE HOME INC.FACILITY NUMBER:
425801657
ADMINISTRATOR/
DIRECTOR:		MERLA P. VENTURAFACILITY TYPE:
740
ADDRESS:1603 LA SALLE DRIVETELEPHONE:
(805) 287-9570
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY: 6CENSUS: 4DATE:
09/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Merla Ventura, Administrator TIME VISIT/
INSPECTION COMPLETED:
03:08 PM
NARRATIVE
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Licensing Program Analyst (LPA) Miller arrived at 8:45 am to conduct a 1 year annual visit to the facility above. LPA met with Administrator, Merla Ventura and explained the purpose of the visit.

A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit:

Infection Control: The facility has a current Infection Control Plan, The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectant spray and cleaners. The facility has a 30-day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE).

Physical Plant & Environment Safety: The fire extinguisher was last charged and inspected on 4/18/24. The facility has 3 resident bedrooms and 2 bathrooms. LPA was authorized to enter and inspect facility. The facility has a smoke and carbon monoxide detector that was tested and was working properly during visit. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. LPA observed a bottle of Clorox bleach was left near toilet and accessible to residents in care. Administrator immediately removed bleach. The facility has sufficient space inside and outside for activities and visiting. The facility has a secured backyard and front patio for client use with plenty of shade. The facility has telephone and internet service for resident use.
Continued 809-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 09/13/2024 03:08 PM - It Cannot Be Edited


Created By: Erika Miller On 09/13/2024 at 10:22 AM
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: LA SALLE CARE HOME INC.
FACILITY NUMBER: 425801657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(f)

(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on an interview, the licensee did not comply with the section cited, as licensee was unalbe to provide any peronnel records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
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Provide CCL with all required documents from personnel file: 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, and education requirements.
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:Kelly Burley
LICENSING EVALUATOR NAME:Erika Miller
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024


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Document Has Been Signed on 09/13/2024 03:08 PM - It Cannot Be Edited


Created By: Erika Miller On 09/13/2024 at 12:17 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: LA SALLE CARE HOME INC.
FACILITY NUMBER: 425801657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with this section when family member performed work and did not have criminal record clearance which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/14/2024
Plan of Correction
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LPA observed Licensee excuse worker from her duties and Licensee agreed to not have anyone perform work without being fingerprinted.
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:Kelly Burley
LICENSING EVALUATOR NAME:Erika Miller
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024


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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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: LA SALLE CARE HOME INC.
FACILITY NUMBER: 425801657
VISIT DATE: 09/13/2024
NARRATIVE
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Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 6/23/25. The facility is approved for a capacity of 6. The fire clearance is granted for 2 ambulatory, and 4 non-ambulatory. Hospice is approved for 1.

Staffing: The facility currently employes 2 full time staff. Staff records were not available at the time of inspection. LPA observed a female cleaning kitchen, bathroom and preparing food for resident. Administrator identified worker as a family member helping for the day. It was determined that family member did not have a background clearance completed and was required to leave the premises. Administrator Certificate is expired.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. LPA reviewed 4 resident files for signed Admission Agreements, Safeguard for property and valuables, LIC 602A Physicians report, Appraisals Needs and Services Plan, Emergency and ID forms.



Food Service: The facility has 2-day perishables and 7-day non-perishables and plenty extra, to meet the food service requirement. LPA observed that freezer stored in garage is defrosting, as there were signs of melted ice in frame of door. Administrator will have repairman look at freezer as soon as possible.

Incidental Medical Services: The facility uses Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed resident medications and observed that Administrator made notations on pharmacy label. Administrator was advised not to alter labels. LPA observed that medications were not expired and were kept in their original containers.

Residents with Special Health Needs: The facility does accept dementia residents in care. The facility currently has residents receiving home health services.


SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024
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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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: LA SALLE CARE HOME INC.
FACILITY NUMBER: 425801657
VISIT DATE: 09/13/2024
NARRATIVE
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Pursuant to Title 22 of the CA Code of Regulations, deficiencies were cited (refer to LIC 809-D) and a civil penalty was assessed.

An exit interview was conducted, a copy of the report, Civil Penalty, and appeal rights were issued.
Exit interview conducted and copy of report printed for Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024
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Page: 17 of 17
Document Has Been Signed on 09/13/2024 03:08 PM - It Cannot Be Edited


Created By: Erika Miller On 09/13/2024 at 01:02 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: LA SALLE CARE HOME INC.
FACILITY NUMBER: 425801657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
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.

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 as bleach was left unattended in bathroom, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/14/2024
Plan of Correction
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Administrator agreed to submit a statement of understanding that all cleaning solutions and disinfectants must be inaccesible. Administrator also agreed to repair lock on cabinet under kitchen sink.
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Disregard--- unalbe to delete- Merla Ventura 1st aid expires 9/21/25
Roger Ventura 1st aid expires 9/25/25
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:Kelly Burley
LICENSING EVALUATOR NAME:Erika Miller
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024


LIC809 (FAS) - (06/04)
Page: 14 of 17
Document Has Been Signed on 09/13/2024 03:08 PM - It Cannot Be Edited


Created By: Erika Miller On 09/13/2024 at 01:02 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: LA SALLE CARE HOME INC.
FACILITY NUMBER: 425801657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(d)
Personnel Records
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited as there is no active administrtor certificate on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
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Administrator agrees to complete certification process by POC.
Type B
Section Cited
HSC
1569.695(e)(2)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above as an Appraisal Needs and Services form was not included in resdient file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
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Administrator will create an Appraisal Needs and Services Plan for all residents in care by POC.
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:Kelly Burley
LICENSING EVALUATOR NAME:Erika Miller
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024


LIC809 (FAS) - (06/04)
Page: 15 of 17
Document Has Been Signed on 09/13/2024 03:08 PM - It Cannot Be Edited


Created By: Erika Miller On 09/13/2024 at 01:02 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: LA SALLE CARE HOME INC.
FACILITY NUMBER: 425801657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(6)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on a record review, the licensee did not comply with the section cited above in resdient records did not inlcude current appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
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Administrator agrees to submit updated appraisals by POC.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kelly Burley
LICENSING EVALUATOR NAME:Erika Miller
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024


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