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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609722
Report Date: 12/03/2024
Date Signed: 12/03/2024 10:59:32 AM

Document Has Been Signed on 12/03/2024 10:59 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:GRANNYS HOMEFACILITY NUMBER:
567609722
ADMINISTRATOR/
DIRECTOR:		HERNANDEZ, VICTORFACILITY TYPE:
740
ADDRESS:1831 BERNADETTE STTELEPHONE:
(805) 278-2273
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY: 6CENSUS: 6DATE:
12/03/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Victor HernandezTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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 09:35 a.m. Licensing Program Analyst (LPA) Esther Cortez, conducted an unannounced case management- deficiencies visit at the above location. LPA met with Administrator Victor Hernandez and Assistant Administrator Celesty Hernandez and explained the reason for the visit.

During the Department’s investigation of death report for Resident #1 (R1) the following deficiencies were observed:

The facility did not submit a Special Incident Report (SIR) to Community Care Licensing (CCL) to notify that Resident #1 (R1) was diagnosed at St. John’s Medical Center Hospital on 04/09/2024 with a Urinary Tract Infection (UTI).

During today's visit, at 09:40 a.m. LPA Cortez observed two chain door locks on the front door of the home. One placed on the top region of the door and the other on the bottom region of the door. The chain door locks were removed during today's visit.

Citations issued, exit interview, appeal rights given.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
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 12/03/2024 10:59 AM - It Cannot Be Edited


Created By: Esther Cortez On 12/03/2024 at 10:13 AM
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: GRANNYS HOME
FACILITY NUMBER: 567609722

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/03/2024
Section Cited
CCR
87468.1(a)(6)

1
2
3
4
5
6
7
87468.1(a)(6) Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following...(6) To leave or depart the facility at any time and to not be locked into any..., building...This requirement is not met as evidenced by:
1
2
3
4
5
6
7
POC has been met. Door locks were removed during today's visit.
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the section cited above, as the front door had two chain locks which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
12/05/2024
Section Cited
CCR87211(a)(1)(B)

1
2
3
4
5
6
7
87211 Reporting Requirements (a)(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days...(B) Any serious injury...under facility supervision. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The licensee will submit a plan describing how you will ensure reporting requirements are followed. Submit proof to CCL by 12/05/2024.
8
9
10
11
12
13
14
Based on records review, the licensee did not comply with the section cited above as they did not submit an incident report when R1 was diagnosed at St. John’s Medical Center Hospital on 04/09/2024 with a Urinary Tract Infection (UTI), which posed a potential health and safety 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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


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