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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850150
Report Date: 01/20/2023
Date Signed: 01/20/2023 03:15:35 PM

Document Has Been Signed on 01/20/2023 03:15 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:VARENITA OF WESTLAKEFACILITY NUMBER:
565850150
ADMINISTRATOR:VEJAR, MERIFACILITY TYPE:
740
ADDRESS:95 DUSENBERG DRIVETELEPHONE:
(805) 413-3300
CITY:WESTLAKESTATE: CAZIP CODE:
91362
CAPACITY: 90CENSUS: 40DATE:
01/20/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Brad StewartTIME COMPLETED:
03:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for a post-licensing visit at 11:15 a.m. The LPA met with Executive Director Brad Stewart and explained the reason for the visit.

The LPA and Executive Director toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Common Spaces: The facility layout includes a garden/subterranean level, the first floor, and the second floor. The garden-level amenities include the main kitchen and dining area, theater, gym, salon, and physical therapy room. The first floor includes the Bistro, activity spaces, and a small outdoor courtyard adjacent to the Bistro. The second floor has several common spaces and a Wellness Center. All indoor and outdoor passages were clean and free of obstruction. There was hands-free sanitizer interspersed throughout the common grounds. Other required postings were posted on the first floor near the elevator.

The LPA toured resident rooms in the Memory Care unit and rooms appeared clean and well maintained. The delayed egress was tested in the memory care unit and was functional at the time of the visit.

There were no obstructions and/or tripping hazards throughout the facility. The fire extinguishers were charged and last serviced 6/2022. Smoke Detectors and Carbon Monoxide detectors were tested within the past 12 months and were operable. Activity rooms and common spaces in both the Memory Care Unit and the Assisted Living areas appeared clean and in good repair.

Bathrooms: Bathrooms were equipped with grab bars and non-skid surfaces. During today's visit, water temperature was tested, and water temperature ranged between 108.6 - 110 degrees Fahrenheit. Bathrooms were stocked with soap and paper towels, and signs promoting good hand hygiene were observed in common restrooms.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE: DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2023
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: VARENITA OF WESTLAKE
FACILITY NUMBER: 565850150
VISIT DATE: 01/20/2023
NARRATIVE
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Kitchen: Facility uses Sysco Foods for food deliveries, and delivery takes place twice a week. Snacks and beverages were available for residents in the Bistro. Food is prepared in the main kitchen and is delivered to the Memory Care Unit.

Staffing: The LPA checked staff associations and identified that Staff #1 (S1) had fingerprint clearance but was not associated to this location. There is a newly hired Administrator. The LPA communicated the documents that were required in order to change the Administrator for this location. This is a zero-tolerance violation. This is an immediate civil penalty and civil penalties will be assessed in the amount of $100 per day for five days ($100 x 5 days).

Grounds: At 1:41 p.m., the LPA and Executive Director observed the courtyard, which is on the garden level. There was a fountain and a waterfall feature observed in the courtyard with flowing water. The waterfall feature had at least two inches of standing water, and the fountain had at least 4-5 inches of water pooled at the bottom of the fountain. At 1:48 p.m., the LPA, Executive Director, and Maintenance Director observed the water feature in the entrance of the community, in which the water feature has approximately 9-10 inches of water pooled at the bottom of the fountain. It was communicated that these water features would be drained of water. It was confirmed that additional rocks would be placed in the water features to ensure water depth does not pose a hazard to residents in care. This is a zero-tolerance violation, which results in a civil penalty in the amount of $500.

Infection Control: Upon entry into the community, the LPA observed that the receptionist was not wearing an appropriate face covering. In addition, guests observed throughout the community were not wearing a face covering. During the physical plant tour, the LPA observed several staff members not wearing an appropriate face covering, including in the memory care unit. There was a central entry point for staff and guests to sign in. Facility had a sufficient supply of Personal Protection Equipment (PPE). The facility’s cleaning protocol was sufficient. The facility keeps record of staff and resident vaccinations. Staff are up to date regarding visitation protocol, screening recommendations for visitors and vaccine requirements. The facility can designate a single-person room to isolate persons if there is a confirmed case of COVID-19. The facility's procedures as it pertains to infection control were adequate.

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. Appeal Rights Discussed. A Copy of the Report Issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/20/2023 03:15 PM - It Cannot Be Edited


Created By: Ashley Smith On 01/20/2023 at 02:38 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: VARENITA OF WESTLAKE
FACILITY NUMBER: 565850150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/20/2023
Section Cited
CCR
87307(e)

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87307(e) Personal Accommodations and Services. Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools, or similar bodies of water...through fencing, covering or other means.
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The Administrator agreed to do the following:
1. Water features will be drained of water by end of the day, 1/20/2023.
2. Rocks would be placed in the water features to ensure water depth does not pose a hazard to residents in care. Send photos once completed.
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This requirement is not met as evidenced by:
Based on observation, the licensee did not comply with the section cited above as the facility had water fountains in the courtyard and in front of the building filled with standing water, which poses an immediate health and safety risk to persons in care.
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Immediate civil penalty assessed of $500.
Type A
01/20/2023
Section Cited
CCR87355(e)(2)

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87355(e)(2) Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... in a licensed facility: (2) Request a transfer of a criminal record clearance…
This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
1. Ensure that S1 is associated to this location. Submit proof to CCL when this has taken place.
Civil penalty assessed for $100 a day, for a maximum of 5 days.
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Based on interviews and observations, the licensee did not comply with the section cited above, as one individual (S1) have been working at the facility without a criminal record transfer, which poses an immediate health and safety risk to residents 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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Ashley Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 01/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/20/2023 03:15 PM - It Cannot Be Edited


Created By: Ashley Smith On 01/20/2023 at 02:39 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: VARENITA OF WESTLAKE
FACILITY NUMBER: 565850150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/27/2023
Section Cited
CCR
87468.1(a)(2)

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87468.1(a)(2) Personal Rights of Residents in All Facilities ...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement was not met as evidenced by:
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The Administrator agreed to do the following:
Administrator agreed to hold training with all staff about proper mask-wearing and COVID-19 prevention protocol for staff and visitors and provide training records to CCL within seven (7) days.
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Based on observations and interview, the licensee did not comply with the section cited above, as staff and guests within the community were not wearing face masks in the facility, which poses a potential personal rights risk to residents 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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Ashley Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 01/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2023


LIC809 (FAS) - (06/04)
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