565800734-8-2-2023-29-AS-ECAS-CUBV2L-20230802160320

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565800734
Report Date: 08/02/2023
Date Signed: 08/02/2023 04:03:53 PM

Document Has Been Signed on 08/02/2023 04:03 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	HILLCREST ROYALE		FACILITY NUMBER:	565800734
ADMINISTRATOR:	INGA JAKOBOVICH		FACILITY TYPE:	740
ADDRESS:	190 EAST HILLCREST DRIVE		TELEPHONE:	(805) 371-0035
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY: 145		CENSUS: 87	DATE:	08/02/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Inga Jackobovich		TIME COMPLETED:	04:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a continuation to a required annual visit at 9:45 a.m. The LPA was greeted by staff and informed them of the reason for the visit. This is an annual continuation, which began on 06/19/2023.

RECORDS: The LPA continued a records review today beginning at 10:00 a.m. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. The LPA continued a records review of staff associations that compared the Licensing Facility Personnel Report Summary dated 6/19/2023 and 8/1/2023 against the facilities most recent LIC 500 dated 3/22/2023 and Guardian. The following was noted: 7 staff (S1, S2, S3, S4, S5, S6, S7) were found not to be associated to the facility. Files contained all required forms however Administrator indicated that staff are usually associated following fingerprinting by the fingerprinting agency and that staff who have been working here for a long period of time were erroneously separated form the facility. LPA advised the Administrator that it is their responsibility to ensure that all staff who are employed are reflected on the association list prior to working at the facility. Facility Personnel Reports are provided to the facility automatically on a yearly basis for review however, Administrator was reminded that they may contact licensing for an updated facility personnel report when they need too. The report is to be used to not only advise the department of any staff who are no longer working at the facility but to also verify that everyone who is working is reflected on the list. S1, S2, S3, S4, S5, S6, S7, have been working at the facility prior to 2021 and Administrator was in possession of a Facility Personnel Report dated 4/7/2021. Civil penalties were assessed.

Residents’ records review began at 12:00 p.m., records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HILLCREST ROYALE	FACILITY NUMBER: 565800734
	VISIT DATE: 08/02/2023

NARRATIVE

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MEDICATIONS: The LPA audited five (5) resident files. The following is observed: medications are labeled and checked for expiration dates. For 1 out of 5 residents (Resident #1), the facility did not administer day 1 of the new bubble pack 8/1/2023 Digoxin as prescribed by R1’s physician. All medications are properly documented on the centrally stored medications and destruction record for 5 out of 5 residents.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

The LPA obtained the following documents: LIC500 Personnel Report, LIC9020 Client Roster.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview was conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/02/2023 04:03 PM - It Cannot Be Edited

Created By: Elsie Campos On 08/02/2023 at 03:31 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: HILLCREST ROYALE	FACILITY NUMBER: 565800734
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(2)

87355(e)(2) Criminal Record Clearance. All individuals subject to a criminal record review ... shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as 7 staff (S1,S2,S3,S4, S5, S6, S7) were not associated to the facility which poses an immediate health and safety risk to persons in care.
	POC Due Date: 08/03/2023
	Plan of Correction
1 2 3 4	The licensee agreed to do the following: 1. Associate staff and submit proof to CCL no later than 8/3/23.

Type A

Section Cited

CCR

87465(a)(4)

87465 (a)(4) Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as 1 morning pill for R1 of DIGOXIN was found to be unadministered for 8/1/2023, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 08/03/2023
	Plan of Correction
1 2 3 4	The licensee agreed to do the following: 1. Complete a plan of action detailing how the facility will ensure compliance with medication administration. Advise CCL no later than 8/3/2023. 2. Conduct in-service for staff on medication distribution and advise CCL no later than 8/11/23.

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:

Jeralyn Ann Pfannenstiel

LICENSING EVALUATOR NAME:

Elsie Campos

LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

LIC809 (FAS) - (06/04)

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