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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801541
Report Date: 01/09/2024
Date Signed: 01/09/2024 03:21:21 PM

Document Has Been Signed on 01/09/2024 03:21 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:FINEST LIVING AT CRESTWOODFACILITY NUMBER:
565801541
ADMINISTRATOR:ADELAIDA G. CRUZFACILITY TYPE:
740
ADDRESS:225 CRESTWOOD AVENUETELEPHONE:
(805) 620-0739
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY: 6CENSUS: 6DATE:
01/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Adelaida CruzTIME COMPLETED:
03:30 PM
NARRATIVE
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At 10:05 a.m. Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by staff Alex Garcia and informed them of the reason for the visit. Licensee Adelaida Cruz arrived shortly.

At 10:22 a.m. the LPA conducted a tour of the physical plant with the staff and Licensee to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The following was noted: Facility is a single-story residence that consists of two (2) living rooms, six (6) resident bedrooms, one (1) staff room, one (1) laundry room, two (2) communal restrooms and one (1) private resident restroom. The LPA observed fire extinguishers which were fully charged, however they were last serviced in October 2022. All smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed all required postings.

Kitchen: During the facility tour at 10:22 a.m. the kitchen appeared clean and the appliances and fixtures functional. LPA observed sufficient amount of perishable and non-perishable food at the facility. Food is prepared based on the menu. Snacks and beverages are always available for the residents.
Bedrooms: The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. At 10:37 a.m. the auditory alarm on the exit door to the backyard in room #5 was observed to not be working. During the tour the LPA observed hygiene/grooming items in rooms #2 ,#3, and #4, and all rooms in the facility were unlocked and open. The facility serves residents with dementia and residents who are at risk if allowed direct contact with grooming/hygiene items. At 10:40 a.m. the LPA observed Aquaphor healing ointment in room #4. At 10:46 a.m. the LPA observed, stained walls, stained bed sheets, two boxes of powdered Vitamin C, and a tube of athletes foot ointment in room #3. Report will continue on LIC809-C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2024
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: FINEST LIVING AT CRESTWOOD
FACILITY NUMBER: 565801541
VISIT DATE: 01/09/2024
NARRATIVE
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Bathrooms: The LPA observed all bathrooms with functional fixtures, grab bars and non-skid mats. At 10:33 a.m. the LPA observed a bottle of Lysol toilet bowl cleaner in the communal resident bathroom, and observed the restroom to be unkempt with stains in the toilet, walls and upswept floor. At 10:50 a.m. the LPA observed the restroom inside room #3 unkempt with stains and residue in the shower floor, toilet and on the floor. At 11:24 a.m. water temperature in resident’s restroom was measured at 120 degrees Fahrenheit.

Common Areas: These included the living rooms and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a fireplace in both livings room, which were covered with a screen. The facility maintained a comfortable temperature of 70 degrees. There were no obstructions and/or tripping hazards throughout the facility. At 11:16 a.m. the LPA observed the living room screen door not properly installed , and observed the auditory alarm on the sliding glass door to not be properly working.

The garage & Laundry room: The LPA observed the laundry room locked. The laundry room is connected to the garage and attic, which are both being used for storage. Cleaning supplies and disinfectants are kept in locked cabinets.


Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water on the premises.
Infection Control: The home has an adequate supply of Personal Protection Equipment (PPE) and can obtain additional supplies.
Record Review: At 11:30 p.m. a review of facility files was initiated. The LPA reviewed five (5) out of six (6) resident files. The LPA identified that one out of five residents (R1) requires an updated physician’s report (LIC602), and an updated appraisal needs and service plan due to the diagnosis of dementia. Two (2) out of five (5) residents (R2,R3) require an updated appraisal/ needs and service plan LIC625. The LPA reviewed five (5) of five (5) staff files. One out of five staff (S1) did not have Tuberculosis test results on file.
Interviews: The LPA conducted two (2) resident Interviews. No immediate concerns were voiced.

Due to time constraints the LPA will return to complete the annual at a later date.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided to Licensee.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 01/09/2024 03:21 PM - It Cannot Be Edited


Created By: Esther Cortez On 01/09/2024 at 02:22 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: 01/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) 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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the LPA observed vitamins, Lysol toilet bowl cleaner, over the counter healing ointment and groomiing/hygiene accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/12/2024
Plan of Correction
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Administrator agreed remove and secure all items inaccessible to the residents in care today and provide documentation of staff inservice training regarding regulation 87705(f)(2) to CCL by 1/12/2024.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 01/09/2024 03:21 PM - It Cannot Be Edited


Created By: Esther Cortez On 01/09/2024 at 02:22 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: 01/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

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 in one out five staff need TB results, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/19/2024
Plan of Correction
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The Administrator has agreed to do the following:
1. Obtain S1 Tb TEST. Inform the Department when this has taken place, but no later than 1/19/2022

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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 01/09/2024 03:21 PM - It Cannot Be Edited


Created By: Esther Cortez On 01/09/2024 at 02:22 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: 01/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

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 fire extinguishers were serviced over a year ago which poses/posed a potential health, safety or personal rights risk to persons in care
POC Due Date: 01/19/2024
Plan of Correction
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The Licensee has agreed to have fire extinguishers serviced or purchase new fire extinguisher and show proof to CCL by 1/19/2024.
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

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 one resident requires an updated medical assesment and a appraisal/needs and services which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/19/2024
Plan of Correction
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Adiministrator agrees to obtain residents updated medical assesment and needs and service plan no later than POC due date and submit proof to CCL by 1/19/24.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 01/09/2024 03:21 PM - It Cannot Be Edited


Created By: Esther Cortez On 01/09/2024 at 02:22 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: 01/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

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 the exit door in room #3 and sliding glass door in the living room were observed with auditory alarms turned off which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/09/2024
Plan of Correction
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Auditory alarms were turned on during the visit, POC has been met.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024


LIC809 (FAS) - (06/04)
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