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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850255
Report Date: 07/05/2024
Date Signed: 07/05/2024 01:21:54 PM

Document Has Been Signed on 07/05/2024 01:21 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:CALIFORNIA CARE RCFE BAXTERFACILITY NUMBER:
565850255
ADMINISTRATOR/
DIRECTOR:		OBTINALLA, MC RICHARDFACILITY TYPE:
740
ADDRESS:283 BAXTER STREETTELEPHONE:
(818) 448-2967
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91320
CAPACITY: 6CENSUS: 5DATE:
07/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:58 AM
MET WITH:Arnida ObtinallaTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analysts (LPAs) Trevor Byrne and Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 08:58AM. LPAs were greeted by staff who contacted Facility Designee Arnida Obtinalla who arrived at the facility at approximately 09:00AM. Entrance interview conducted.

Beginning at 09:00AM, the LPAs, along with Facility Designee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: The LPAs observed the kitchen/dining area to be clean. Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) days perishable and two (2) days non-perishable food and emergency water. The LPAs observed one designated cabinet where knives and sharps are stored locked and inaccessible to residents. Cleaning supplies are located in a locked cabinet under the kitchen sink.

LAUNDRY & GARAGE: The laundry room is located adjacent to the kitchen. Laundry supplies and chemicals are stored in a locked cabinet, inaccessible to residents in care. Garage was observed locked and contained an additional freezer and pantry, which contained adequate emergency supplies.

COMMON AREAS: This includes the living room and dining room areas. LPAs observed common area to be clean and properly furnished at the time of the visit. Fireplace was noted to be screened and inaccessible to residents. The LPAs observed the fire extinguisher to be fully charged and purchased on 05/29/2024. Hardwired smoke detectors and carbon monoxide detectors were tested at 09:31 AM and were functional at the time of the visit.
Report Continued on LIC 809-C
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE: DATE: 07/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/05/2024
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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Document Has Been Signed on 07/05/2024 01:21 PM - It Cannot Be Edited


Created By: Trevor Byrne On 07/05/2024 at 12:12 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: CALIFORNIA CARE RCFE BAXTER
FACILITY NUMBER: 565850255

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:

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 1 out of 3 resident medication records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2024
Plan of Correction
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Designee will submit either an updated PRN authorization letter or an updated PRN medication log with accurate times physician was contacted and medication was administered.
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:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2024


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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: CALIFORNIA CARE RCFE BAXTER
FACILITY NUMBER: 565850255
VISIT DATE: 07/05/2024
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Continued from LIC 809

BEDROOMS: There are five (5) bedrooms in the facility; four (4) bedrooms are designated for resident use, including two (2) shared rooms, and two (2) private rooms, as well as one (1) staff room. The staff room is kept locked. All 4 (four) resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

BATHROOMS: There are two (2) bathrooms for resident use, one (1) of which is a shared resident restroom located in the hallway and one (1) is a private resident restroom. Restrooms were observed to be equipped with nonskid surfaces and contain nonskid mats. Grab bars were observed in the bathrooms. The water temperature was measured in the shared resident bathroom to be 114.8 degrees at 09:18 AM. The water temperature in the private bathroom was measured to be 118.6 degrees at 09:29 AM. Both restrooms were measured to be within the required range.

OUTDOOR SPACE: The backyard has a covered patio area with patio furniture including a table and chairs for resident use. Facility has two total gates, one (1) gate was observed to be self-latching and closing with clear passageways for emergency exit use. There were no bodies of water on the premises at the time of the visit.



RECORD REVIEW: Began at 09:37AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights.

MEDICATION REVIEW: Began at 10:15 AM. Medications for three (3) of five (5) residents were observed. One (1) resident (Resident 1 – R1) had PRN (as needed) medications prescribed. The doctor for R1 indicated that the resident can not communicate their need for the medication. Based on record review the facility lacked a record of the times the physician was contacted to administer these medications.

Report Continued on LIC 809-C
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2024
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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: CALIFORNIA CARE RCFE BAXTER
FACILITY NUMBER: 565850255
VISIT DATE: 07/05/2024
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Continued from LIC 809-C

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPAs reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Last emergency disaster drill was conducted 04/27/2024.

INTERVIEWS: LPAs interviewed two (2) staff and three (3) residents.

The following deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Licensee was advised that failure to correct the deficiency may result in civil penalties.

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

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2024
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