567609601-10-31-2022-29-AS-BBAI-CJNRQK-20220927131341

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609601
Report Date: 09/27/2022
Date Signed: 10/31/2022 10:00:04 AM

Document Has Been Signed on 10/31/2022 10:00 AM - 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:	ARIANAH PLACE INC		FACILITY NUMBER:	567609601
ADMINISTRATOR:	GUEVARRA, ESTILITO		FACILITY TYPE:	740
ADDRESS:	53 WALES STREET		TELEPHONE:	(805) 870-4518
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY: 6		CENSUS: 6	DATE:	09/27/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Erlinda Gonzales - Licensee		TIME COMPLETED:	01:30 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	At approximately 11:30am, Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. LPA was greeted and screened by staff. LPA met with Licensee Erlinda Gonzales and explained the reason for the visit. This annual had a specific emphasis on infection control practices and procedures. LPA 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. At 11:30am, LPA observed (2) staff members not wearing any face coverings while servicing residents in care. LPA observed the kitchen/dining area. Knives were observed stored in a locked cabinet under the sink. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food properly stored. Medications were observed stored in a locked cabinet to the right of the fridge inaccessible to residents in care. First aid kits were observed stored in a cabinet at entry way of kitchen. No sharp objects or other items were observed stored with first aid kits at this time. At 11:35am, LPA observed staff member preparing snacks. All Restrooms were observed relatively clean, sanitary and in operating condition with grab bars and non-skid mats. Hot water measured between 105 - 115 degrees Fahrenheit. LPA observed fire extinguishers to be fully charged and last serviced in November of 2021. LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. At 11:45am, LPA observed (4) residents watching television in the living room. Continued on 809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022

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 10/31/2022 10:00 AM - It Cannot Be Edited

Created By: Brian Balisi On 09/27/2022 at 12:40 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: ARIANAH PLACE INC	FACILITY NUMBER: 567609601
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87468.1(a)(2)

Personal Rights of Residents in All Facilities: Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above as staff did not wear face coverings at all times while inside the facility, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 09/28/2022
	Plan of Correction
1 2 3 4	The Licensee agreed to advised staff on wearing masks at all times inside the facility and conduct a training on CA Dept of Public Health Guidance for the use of face coverings and COVID-19 screening protocols and submit proof to LPA via email by end of day 09/28/2022

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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:

Desaree Perera

LICENSING EVALUATOR NAME:

Brian Balisi

LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022

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: ARIANAH PLACE INC	FACILITY NUMBER: 567609601
	VISIT DATE: 09/27/2022

NARRATIVE

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Continued from 809

Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. LPA observed cabinet at central entry point to store a sufficient supply of PPE. There is an attached garage that was observed to be locked and inaccessible to residents in care. LPA observed extra medical equipment, medical supplies, decorations as well as (2) extra fridges with perishable food properly stored. Each exit way that led to the outside activated a centralized notification system that would indicate which door sensor was activated.

Surrounding Grounds (Outdoors): There was a shaded outdoor area with multiple pieces of furniture appropriate for outdoor use in the rear of the facility. There are no bodies of water on the premises. LPA observed exit ways were free of obstruction at this time.

The LPA spoke with Erlinda regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to isolate each resident in their private room if the facility has a confirmed case of COVID-19. COVID-19 testing is conducted weekly if anyone shows any symptoms. The facility’s policies and procedures as it pertains to infection control are adequate at this time.

Citations Issued. See LIC 809D. Appeal Rights discussed. Exit interview conducted and copy of the report emailed to Administrator.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022

LIC809 (FAS) - (06/04)

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