VARIEL OF WOODLAND HILLS, THE

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above as four (4) out of seven (7) care staff files observed were missing valid first aid certification from a qualified agency which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 08/19/2025 Plan of Correction ED stated that staff will get valid first aid certification either in-service at the facility or by an outside qualified agency and will send proof to CCL by 08/19/2025.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465(a)(4) Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility…(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on record review & interviews, the licensee did not comply with the section cited above, staff did not properly assist R1’s medications per physician’s order which poses an immediate health and safety risk to residents in care.

Official plan of correction

Within 24 hours, the ED will provide the LPA with proof of medication training.

Deadline recorded: Jun 14, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements(a) ... (1) A written report shall be submitted to the licensing agency…within seven days of the occurrence of any of the events... (D) Any incident which threatens the welfare, safety or health of any resident…This requirement is not met as evidenced by: Based on interviews & records review, the licensee did not comply with the section cited above as the Licensee did not report to R1’s responsible person of R1’s medication refusal which poses a potential health, safety, or personal rights risk to residents in care.

Official plan of correction

Wellness Director stated they will submit a statement of understanding confirming that they understand the importance of reporting any incidents, including medication refusal to residents’ responsible persons. Additionally, Wellness Director stated that an in-service training regarding reporting requirements will be conducted and proof will be sent to the LPA.

Deadline recorded: Jun 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on interviews and observation, the Licensee did not comply with the section cited above as R1 and R2 left the memory care floor unsupervised with the elevator which posed a potential health, safety, and personal rights risk to residents in care.

Official plan of correction

Facility management contacted maintenance during the visit and put a service request to install key fob pads outside of the memory care elevators or to restrict the key fob pads inside the elevators to prevent memory care residents taking the elevator down. ED will submit proof to CCLD by 06/04/2025.

Deadline recorded: Jun 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being... This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above as 2 out of 3 resident apartment doors did not have functioning door closers which poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

Administrator notified the maintenance team during the visit and the 2 door closers were repaired. Administrator agreed to audit all resident apartment doors for functioning door closers and will submit a signed statement of all doors in good repair to CCL by 04/09/2025.

Deadline recorded: Apr 9, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(g)(1)

Regulation authority

CCR

What the official deficiency says

All personnel records shall be maintained at the facility and shall be available…licensing agency for review. (1) The licensee shall be permitted to retain such records in a central …location provided that they are readily available to the licensing… This requirement is not met as evidenced by: Based on interviews, licensee did not comply with the above section by not having 2 out of 14 files (S1, S2) readily available for CCL to review, which is a potential risk to residents in care.

Official plan of correction

Administrator agreed to submit a letter of understing that files shall be available to Licensing by POC due date.

Deadline recorded: Mar 15, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

Criminal Record Clearance. (e) All individuals subject to a criminal record review ... shall prior to working, residing, or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance...This requirement is not met as evidenced by: Based on record review, and interviews, licensee did not comply with the above section by not ensuring 3 out of 3 (S1, S2 and S3) had fingerprint association transferred to the facility prior working, which poses an immediate health and safety risk to residents in care.

Official plan of correction

Administrator agreed to make sure all staff are associated to the facility and submit proof by POC due date.

Deadline recorded: Mar 9, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(23)

Regulation authority

CCR

What the official deficiency says

General Food Service Requirements. (b) The following food service requirements shall apply: All readily perishable foods or beverages capable of... which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement is not met as evidenced by: Based on observation and interviews, licensee did not comply with the section above by not covering and labeling the multiple ice cream tubs in the freezer, which is a potential health and safety risk to residents in care.

Official plan of correction

Administrator agrees to provide trainig regarding General food service requierement by POC due date.

Deadline recorded: Mar 11, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a)(3)To be free from punishment, humiliation, intimidation, abuse, or other actions...interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidenced by: Based on interview, review of witness statements and bruising observed on R1, S1 reportedly pinched R1's nipples to awaken R1, which poses an immediate health, safety, and personal rights risk to residents in care.

Official plan of correction

Administrator indicated that S1 is not currently working, pending results of the investigation. Remaining staff were trained on 12/20/2023 on Resident Personal Rights and putting residents to sleep in their beds. Administrator will follow up with CCL by POC due date related to the employment status of S1.

Deadline recorded: Jan 3, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

87468.1Personal Rights of Residents in All Facilities (a)(3)To be free from punishment, humiliation, intimidation, abuse, or other actions...interfering with daily living functions such as eating, sleeping, or elimination.This requirement is not met as evidence by: Based on Records obtained. The licensee did not comply with the above cited section as S1 was observed forcefully gripping and forcefully sitting R1 which poses an immidiate personal rights risk to residents in care.

Official plan of correction

Plan of correction has been met as S1 is no longer working at the facility.

Deadline recorded: Sep 28, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Deficient Practice Statement Based on a medication audit, the licensee did not comply with the section cited above as 3 out of 5 resident medication pill count was not concuring with documentation which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/20/2023 Plan of Correction Administrator will conduct a medication audit on the 3 resident medications. Administrator will submit a letter to CCL indicated the audit was completed.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as medication was accessible in an unlocked office which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/20/2023 Plan of Correction Medication was secured during today's visit. Administrator will conduct all staff training on ensuring medications are kept inaccesssible at all time.

Official classification

Type B

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on medication audit, the licensee did not comply with the section cited above 3 out of 5 Centrally Stored Medication and Destruction Records was not up to date which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/04/2023 Plan of Correction Administrator will conduct a medication audit on the 3 resident medications. Administrator will submit a letter to CCL indicated the audit was completed.

Official classification

Type B

Official code

87555(b)(23)

Regulation authority

CCR

What the official deficiency says

(23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above pies, bread and vegetables where not properly covered which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/04/2023 Plan of Correction Food items were properly covered during today's visit. Administrator will conduct kitchen staff training on section 87555(b)23).

Official classification

Type B

Official code

87555(b)(24)

Regulation authority

CCR

What the official deficiency says

General Food Service Requirements (24) Pesticides and other toxic substances shall not be stored in food storerooms, kitchen areas, or where kitchen equipment or utensils are stored. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as disinfectant wipes were obserevd in the kitchen area which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/04/2023 Plan of Correction Disinfectant wipes were secured in a different location. Administrator will conduct kitchen staff training in section 87555(b)(24).

Official classification

Type B

Official code

87555(b)(27)

Regulation authority

CCR

What the official deficiency says

General Food Service Requirements (b)(27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as the kitchen area was observed unclean and not sanitary which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/04/2023 Plan of Correction Administrator will submit a plan on how they will maintain the kitchen area in clean and sanitary. Administrator will submit documentation of plan to CCL by 8/4/23.

Official classification

Type B

Official code

87468(a)(1)

Regulation authority

CCR

What the official deficiency says

87468.1(a)(1) Personal Rights of Residents in All Facilities. Residents ... shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on interviews and written statements, the licensee did not comply with the section cited above as S1 humiliated R1 by waving a soiled adult brief in R1's face, which poses a potential personal rights risk to residents in care.

Official plan of correction

Administrator will conduct all staff training on Mandated Reporting, Elder Abuse, Code of Conduct, Resident Rights, and Dementia related behaviors. Administrator will submit all documentation to CCL by 07/21/2023.

Deadline recorded: Jul 21, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations, the licensee did not comply with the section cited above as windex and other cleaning solutions were observed accessible which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/13/2023 Plan of Correction DRCS locked away items. DRCS will conduct staff training on section 87309(a) and sent copies of training to CCL by 06/14/2023.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as variousresident water temperature was observed to be over 120.0 degree F which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/14/2023 Plan of Correction Administrator will lower the temperature for buildings A,B,C. Administrator will take 3 times a day, for 3 days temperature reading on 15 random resident rooms and submit to CCL by 06/16/2023.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care(c)(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based on interviews, the license did not comply with the section above as an incident report, DRCS and S1 admitted to a medication error which indicated that R1 was administered nasal spray solution to their right eye which posed an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

Administrator will conduct ongoing medication training with all staff who handle medication. Administrator will submit medication plan for the year to CCL by 05/25/2023.

Deadline recorded: May 25, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

87463(a) Reappraisals.The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above as R2's care needs are not accurately reflected on the most recent care plan, which poses a potential health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to do the following: 1. Reassess R2, and update R2's care plan to accurately reflect R2's care needs. Submit updated care plan to CCL by 9/16/2022.

Deadline recorded: Sep 16, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87458(c)

Regulation authority

CCR

What the official deficiency says

87458(c) Medical Assessment. The licensee shall obtain an updated medical assessment when required by the Department. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above, as R2's medical assessment does not reflect R2's capacity for ADL care, which poses a potential health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to do the following: 1. Obtain an updated medical assessment for R2. Submit medical assessment by 9/23/2022.

Deadline recorded: Sep 23, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. Residents shall have all of the following...: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above, as R1 was handled in a manner which resulted in R1 sustaining bruises, which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to do the following: 1. Submit a Statement of Understanding, noting the measures staff will take to lower the risk of residents developing bruises. Submit the Plan of Action to CCL by 9/14/2022. 2. Host an in-service training regarding appropriate transferring methods and working with residents with skin integrity issues. Submit sign-in sheet and any training materials. Training must be done by 9/23/2022.

Deadline recorded: Sep 14, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211(a)(1)(D). Reporting Requirements. Each licensee shall furnish to the licensing agency such reports as the Department may require, including: Any incident which threatens the welfare, safety or health of any resident. This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above, as the facility did not submit an unusual incident report regarding, the bruises observed on R1, which poses a potential health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to do the following: 1. Submit an unusual incident report regarding the 8/20/2022 occurrence of the bruise. Submit incident report by 9/16/2022.

Deadline recorded: Sep 16, 2022. A deadline is not proof that correction was completed.