WOODLAND HILLS RETIREMENT HOME

Official classification

Type B

Official code

87465(h)(1)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: This requirement is not met as evidenced by: Deficient Practice Statement Based on medication review, the licensee did not comply with the section cited as medications were not stored in their original containers, logs were missing medication quantities and had start dates for future dates, and Resident #1's medication had pill count discrepancies which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 06/05/2026 Plan of Correction Administrator stated the facility will no longer utilize weekly pill organizers and will conduct medication training with all staff regarding medication administration, properly logging medications, and storing medications. Administrator will submit proof to CCLD by the due date.

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 hot water in three (3) out of three (3) bathrooms measured outside of the required range of 105-120 degrees F which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/29/2025 Plan of Correction Staff immediately lowered the water heater settings on both water heater tanks during the visit. Administrator assistant stated they will monitor hot water in the bathrooms and will send a 5 day water temperature log to CCL.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

87355(e)(1) Criminal Record Clearance. Prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption This requirement is not met as evidenced by: Based on observation, record review, and interview, Staff #1 did not have a criminal record clearance which poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

Administrator stated that fingerprints were submitted today and S1 will be associated. Administrator will submit proof by 01/16/2025 to CCL.

Deadline recorded: Jan 16, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above as two employees were observed without a criminal record clearance which poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

Licensee stated that the two staff are associated to his other facility and will transfer their criminal record clearance by today. Licensee will submit proof to CCL by 10/31/2024.

Deadline recorded: Oct 31, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h)The following requirements shall apply to medications...: (5)Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above as medications were stored in pill boxes three days in advance which poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

Licensee stated that they will conduct a meeting with all staff to discuss medication preparation and storage. Licensee will submit proof to CCL by 10/31/2024.

Deadline recorded: Oct 31, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(d)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (d)If the resident is unable to determine his/her own need for a...PRN medication...facility staff...shall be permitted to assist the resident...provided all of the following requirements are met: This requirement is not met as evidenced by: Based on medication review, the licensee did not comply with the section cited above as PRN medications for 3 residents were not properly logged which poses a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

Licensee stated they will conduct training with staff to address PRN medication logging to ensure that Rx number, date filled, and date expired are logged. Licensee will submit proof to CCL by 11/07/2024.

Deadline recorded: Nov 7, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws... This requirement is not met as evidenced by: Based on interviews and medication and record reviews, the licensee did not comply with the section cited above as 3 medications were not properly maintained which poses an immediate health, safety, and personal rights risk to residents in care.

Official plan of correction

Licensee contacted a hospice nurse to discuss medications on 10/27/2024. Licensee is an LVN and will conduct medication training to all staff and submit proof to CCL by 10/31/2024.

Deadline recorded: Oct 31, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

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 observation, interview, and audit, the licensee did not comply with the section cited above in three (3) out of medications packets/bottles were incorrectly documented in the LIC622 and which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/07/2024 Plan of Correction The Licensee Representative agreed to contract a vendor to provide medication traning to all staff and administrators and licensee, by June 7/2024.The Licensee will email the certified training to the CCLD LPA all training docuemnts.

Official classification

Type B

Official code

1569.695(a)(1)

Regulation authority

HSC

What the official deficiency says

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (1) Evacuation procedures, including identification of an assembly point or points that shall be included in the facility sketch. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in one out of one evacuation plan sketch was not posted, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/07/2024 Plan of Correction Licensee representative agreed to send picture of posted Evacuation Plan.

Official classification

Type B

Official code

87212(c)

Regulation authority

CCR

What the official deficiency says

(c) Emergency exiting plans and telephone numbers shall be posted. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in one out of out of one emregncy procedures were not available and posted, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/07/2024 Plan of Correction Licensee representative agreed to send picture of posted Emergecy Plan.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. 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 6 out of 7 staff members did not have their Tuberculosis test or immunizations which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/26/2023 Plan of Correction Administrator will submit immunization card exempting TB test or have staff members test for TB. Administrator will submit documentation by 05/26/2023 to CCL.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. 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 7 out of 7 staff did not have the initial and annual training which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/09/2023 Plan of Correction Administrator will provide 40 hours of training for all staff members. Administrator will submit documentation to CCL by 06/09/2023.

Official classification

Type B

Official code

87458(b)(1)

Regulation authority

CCR

What the official deficiency says

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. 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 1 out of 6 residents did not have Tuberculosis which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/26/2023 Plan of Correction Administrator will have resident TB tested. Administrator will provide proof to CCL by 05/26/2023.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) 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. Significant changes shall include but not be limited to: 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 in 5 out of 6 residents did not have their initial Needs and Service plan signed and 1 resident did not have a re-appraisal based on change in condition which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/31/2023 Plan of Correction Administrator will submit signed Needs and Appraisal and Re-appraisal to CCL by 05/31/2023.

Official classification

Type B

Official code

87465(d)

Regulation authority

CCR

What the official deficiency says

(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 Based on record review, the licensee did not comply with the section cited above as 6 out of 6 residents did not have their PRN Authorization Letter which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/31/2023 Plan of Correction Administrator will sent PRN Authorization Letter to resident's Physicians. Administrator will submit copies to CCL 05/31/2023.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. 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 the LPA did not observed the required quartely emergency training which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/07/2023 Plan of Correction Administrator will conduct an emergency drill training for all staff. Administrator will submit proof of training to CCL by 06/07/2023.

Official classification

Type B

Official code

87608(a)(5)(A)

Regulation authority

CCR

What the official deficiency says

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. 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 3 out of 5 residents did not have bed rail orders which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/19/2023 Plan of Correction Administrator will request resident physician bed rail order. Administrator will submit to CCL 05/18/2023.

Official classification

Type B

Official code

87705(c)(3)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance: 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 7 out of 7 staff member did not have Dementia training which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/16/2023 Plan of Correction Administrator will conduct dementia training for all 7 staff members. Administrator will submit proof of training to CCL by 06/16/2023.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465(a)(4) Incidental Medical and Dental. The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on observation, the licensee did not comply in the section cited above for two out of three residents (R1, R2) which poses an immediate health and safety risk to residents in care. The Administrator agreed to the following:

Official plan of correction

The Administrator agreed to do the following: 1. Schedule an in-service training with an outside agency within the next 48 hours and provide proof to CCL no later than 9/15/2022. 2. Host an in-service training with an outside agency around the self-administration of medications, specifically discussing all medication documentation and completing the Centrally Stored Medication and Destruction Record. Training and proof must be completed no later than 9/30/2022.

Deadline recorded: Sep 15, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(6)

Regulation authority

CCR

What the official deficiency says

87465(h)(6) Incidental Medical and Dental Care: The following requirements shall apply to medications which are centrally stored: The licensee shall be responsible for assuring that a record of centrally stored presciption medications...is maintained… This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above, as two (2) out of three (3) resident files did not contain properly completed centrally stored medication logs, which poses a potential health, and safety risk to persons in care.

Official plan of correction

The Administrator agreed to do the following: 1. Host an in-service training with an outside agency around the self-administration of medications, specifically discussing all medication documentation and completing the Centrally Stored Medication and Destruction Record. 2. Update the Centrally Stored Medication Log for all residents and provide proof to CCL no later than 9/23/2022. Training and proof must be completed no later than 9/30/2022.

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

Official classification

Type B

Official code

87307(a)(B)

Regulation authority

CCR

What the official deficiency says

87307(a)(B) Personal Accommodations and Services Living accommodations... shall ... provide...privacy for the residents, staff...(B) No room commonly used for other purposes shall be used as a sleeping room...This requirement is not met as evidenced by: Based on observation, the licensee failed to ensure that common areas were used appropriately, as staff confirmed sleeping on the couch, which poses a potential health and safety risk to residents in care.

Official plan of correction

The Administrator has agreed to do the following: 1. Submit a statement to CCL, stating the appropriate use for common rooms and how they will be utilized. Submit Statement of Understanding by 8/10/22.

Deadline recorded: Aug 10, 2022. A deadline is not proof that correction was completed.

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 2 out 3 restrooms measured water temperatures above 120 degrees Fahrenheit, which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 04/25/2022 Plan of Correction The administrator agreed to do the following: 1. Immediatley adjsut the water temperature on the water heater and notify CCL no later than 4/20/22. 2. Conduct a 5 day temperature check on all sinks and provide a log of measurements to CCL no later than 4/26/22.

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 observation, the licensee did not comply with the section cited above as cleaning supplies were accessible under the kitchen sink and unlcoked garage, which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 04/19/2022 Plan of Correction Administrator agreed to do the following: 1. Immediatley secure all items. Plan of correction met at time of the visit.

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 the LPA observed unlocked and accesible medications in multiple kitchen cabinets, which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 04/19/2022 Plan of Correction The Administrator agreed to do the following: 1. Secure all medications with appropriate locking devices. Plan of correction met at the time of the visit.

Official classification

Type B

Official code

87307(d)(2)

Regulation authority

CCR

What the official deficiency says

(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. 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 water heater door in the backyard was in disrepair and the kitchen diswasher was inoperable, which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 05/06/2022 Plan of Correction The Administrator agreed to the following: 1. Repair or replace dishwasher and water heater door and submit proof to CCL no later than the POC date.

Official classification

Type B

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. 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 there were various expired pershiable items found which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 04/22/2022 Plan of Correction The Administrator agreed to do the following: 1. Dispose of any observed expired foods. Plan of correction met at the time of the visit. 2. Conduct an audit of all perishable and non-perishable foods and dispose of any expired items. Submit proof to CCL no later than POC date.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or 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 in 1 staff at the facility is still pending clearance, which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 04/29/2022 Plan of Correction Administrator agreed to do the following: 1. Send staff home. Plan of correction met at time of the visit. 2. Staff needs to be cleared before working at the facility. Will advise CCL of clearance before staff's return to the facility. Civil Penalties Issued

Official classification

Type B

Official code

87632Id

Regulation authority

CCR

What the official deficiency says

87632 Hospice Care Waiver (d) If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver as necessary to ensure the well-being of terminally ill residents and of all other facility residents, which shall include, but not be limited to, the following requirements: (2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of

Official plan of correction

Administrator will submit a written plan for reporting to CCL any residents who enter into hospice. This will be provided to CCL by 04/01/2022. admission to the facility and the name and address of the hospice. This requirement was not met as evidenced by: No record of licensee reporting R1's entry into hospice to CCL was found, which posed a potential health and safety risk to residents.

Deadline recorded: Apr 1, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87633(h)

Regulation authority

CCR

What the official deficiency says

87633 Hospice Care of Terminally Ill Residents (h) For each terminally ill resident receiving hospice services in the facility, the licensee shall maintain the following in the resident’s record: (4) A copy of the resident’s current hospice care plan approved by the licensee, the hospice agency, and the resident, or the resident’s Health Care Surrogate Decision Maker if the resident is incapacitated. This requirement was not met as evidenced by: Licensee had no records regarding R1's hospice care, including no hospice care plan or hospice care provider visits, which posed a potenital health and safety risk to residents.

Official plan of correction

Administrator will submit a written plan for obtaining and retaining hospice care plans and hospice records. This will be provided to CCL by 04/01/2022.

Deadline recorded: Apr 1, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as

Official plan of correction

Administrator will submit a written plan for reporting unusual incidents to CCL. This will be provided to CCL by 04/01/2022. psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidenced by: Licensee failed to report two incidents of R1 requiring hospitalization, which posed a potential health and safety risk to residents.

Deadline recorded: Apr 1, 2022. 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 Reappraisals (a) 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 was not met as evidenced by: After R1's two inpatient hospitalizations in which hospice was advised due to R1's declining health, licensee failed to complete a reappraisal of R1's condition, which posed a potential health and safety risk to residents.

Official plan of correction

Administrator will submit a written plan for conducting reappraisals of residents when residents have a change in condition. This will be provided to CCL by 04/01/2022.

Deadline recorded: Apr 1, 2022. A deadline is not proof that correction was completed.