<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801541
Report Date: 11/10/2022
Date Signed: 11/10/2022 05:13:02 PM

Document Has Been Signed on 11/10/2022 05:13 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:
11/10/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:02 AM
MET WITH:Adelaida (Aida) CruzTIME COMPLETED:
05:25 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management - Deficiencies inspection due to deficiencies observed during the 11/10/2022 complaint investigation inspection.

The LPA observed the following:

During medication audit for Resident #1 (R1) which began at 12:21PM, LPA observed Triacinolone Acetone Cream 1% is not labeled for R1. An additional medication Chronik Tonic is not listed on the Centrally stored medication record, nor is it on R1's current prescription list. It was listed on the 11/26/2021 list of R1's medications. The Chronik Tonic was observed to be not properly labeled. Staff indicated this medication had not been administered to the resident.

During record review, which began at 01:20PM, LPA observed a physician's report for R1, who has a diagnosis of Dementia, dated 04/13/2021. Additionally, R1 had no needs and service appraisal completed. Licensee indicated R1's hospice nurse had recently completed a head to toe assessment for R1 so a new Physician's Report could be completed by the Doctor.

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 with Licensee Aida Cruz. Today’s reports and appeal rights were reviewed and provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2022
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 11/10/2022 05:13 PM - It Cannot Be Edited


Created By: Kelly Dulek On 11/10/2022 at 03:51 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: 11/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/28/2022
Section Cited
CCR
87465(e)

1
2
3
4
5
6
7
87465 (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician...and a label on the medication...of the following information.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
During today's visit, the expired medication was removed. Licensee agreed to audit all residents' medications to ensure all medications are properly labeled and unexpired. Licensee will complete the audit and inform LPA of audit results by POC due date.
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the above cited section, as R1's medication Chronik Tonic and Triaminolone Acetonide were observed to be not labeled and the Triaminolone Acetonide was expired in 07/20, which poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Type B
11/28/2022
Section Cited
CCR87705(c)(5)

1
2
3
4
5
6
7
87705 Care of Persons with Dementia (c) (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458... and a reappraisal done at least annually... include a reassessment of the resident’s dementia care needs.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee agreed to obtain a recent medical assessment for R1 and complete a needs and service appraisal for R1. Proof will be sent to CCL by POC due date.
8
9
10
11
12
13
14
Based on record review, R1, who has a diagnosis of dementia, had a medical assessment dated 04/13/2021 and no reappraisal in their file, which poses a potential personal rights risk to residents in care.
8
9
10
11
12
13
14
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:Kelly Dulek
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2