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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801541
Report Date: 10/12/2021
Date Signed: 10/12/2021 03:56:14 PM

Document Has Been Signed on 10/12/2021 03:56 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:FINEST LIVING AT CRESTWOODFACILITY NUMBER:
565801541
ADMINISTRATOR:ADELAIDA G. CRUZFACILITY TYPE:
740
ADDRESS:225 CRESTWOOD AVENUETELEPHONE:
(805) 212-8303
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY: 6CENSUS: 6DATE:
10/12/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Adelaida CruzTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) JoAnn Rosales conducted a Case Management - Deficiencies visit at the facility. LPA met with Adelaida Cruz.

During today's visit LPA toured the facility with staff Alex Garcia and reviewed resident records. During facility tour at 10:11 am LPA observed Triamcinolone Acetonide Cream, Hydrocortisone Cream, Desonide Cream in an unlocked case in resident #1 (R1's) room accessible to residents. Staff Garcia stated that they do not know the combination to the lock to lock it so they placed the items in a locked medication closet. During facility tour at 10:15 am with staff Garcia LPA observed wood glue in the dining room accessible to residents. Staff stated that the glue belongs to the contractor working on the kitchen remodel. During facility tour at 10:16 am with staff Garcia LPA observed melatonin, vitamin D3, vitamin C, calcium, vicks vapo rub, aspirin 81 mg, spironolactone 25 mg, amlodipine besylate, carvedilol 12.5 mg, atorvastatin calcium, zestril and nicotine transdermal system patch in an unlocked staff room accessible to residents. Staff stated that they left the door unlocked when they went to answer the front door when LPA arrived. During facility tour at 10:27 am with staff Garcia LPA observed antibiotic + Pain relief cream and alcohol prep pads in R2's room accessible to residents.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted, today's reports and appeal rights were reviewed and emailed to the Administrator.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 10/12/2021 03:56 PM - It Cannot Be Edited


Created By: Joann Rosales On 10/12/2021 at 01:21 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: FINEST LIVING AT CRESTWOOD
FACILITY NUMBER: 565801541

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/22/2021
Section Cited
CCR
87705(f)(2)

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87705 Care of Persons with Dementia(f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
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Staff placed medications in a locked medication closet and locked staff room door. Wood glue was placed in an inaccessible location. Administrator stated that they will provide documentation of staff training regarding regulation 87705(f)(2) to CCL by 10/22/21.
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Based on LPA's observations and record review, the licensee did not comply with the section cited above as over the counter medication, nutritional supplements, vitamins, alcohol and toxic substances were observed accessible to residents which posed an immediate health risk to persons in care.
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Type A
10/22/2021
Section Cited
CCR87465(h)(2)

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87465 Incidental Medical and Dental Care Services (h)(2) 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.

This requirement is not met as evidenced by:
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Staff locked staff room door. Staff place resident medications in a locked medication closet. Administrator stated that she will provide documentation of staff medication training to CCL by 10/22/21.
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Based on LPA's observation, the licensee did not comply with the section cited above as staff and resident medications were accessible to residents which posed an immediate health 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:Kristin Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2021


LIC809 (FAS) - (06/04)
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