The Preserve at Woodland Hills

1569.686 (a) A licensee shall notify thedepartment, the State Long-Term CareOmbudsman, all residents, and, if applicable,their legal representatives, in writing, within two business days... (1) A notice of default...This requirement is not met as evidenced by: Based on interview and record review, Licensee failed to ensure The Department, LTCO, residents and their responsible parties were notified of the default received by Licensee, which caused a potential health and safety risk to residents in care.

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 interview and record review, the licensee did not comply with the section cited above as Resident #1 (R1) was administered Resident #2’s (R2)’s morning medications by Staff #3 (S3). This posed a potential health and safety risk to persons in care.

Based on interview, record review, and observation, the licensee did not comply with the section cited above as staff did not respond to residents calls for assistance in a timely manner, which poses a potential health, safety, and personal rights risk to persons in care.

Based on observation and interview, the licensee did not comply with the section cited above in the facility did not have a call ssystem in resident rooms and bathrooms which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in 5 out of 6 resident restroom sink water did not measure within the required range which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above in 2 residents had access to items their Physician deemed as at risk which poses an immediate health, safety or personal rights risk to persons in care.

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 interview, the licensee did not comply with the section cited above as Resident #1 (R1)'s Benzonatate medication was left unattended by Staff #1 (S1) which Resident #2 (R2) self-administered. This posed a potential health and safety risk to persons in care.

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 medication review and interview, the licensee did not comply with the section cited above as Resident #1 (R1)'s Lorazepam medication was not administered by Staff #1 (S1) as prescribed, which posed a potential health and safety risk to persons in care.

87456 Evaluation of Suitability for Admission(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above as Resident #1 (R1) was admitted without an admission agreement and appraisal which posed a potential health, safety, or personal rights risk to persons in care.

Basic services shall at a minimum include: (a) Care and supervision as defined in Section 1569.2.This requirement is not met as evidenced by:Based on interviews conducted, evidence submitted and file review, the licensee did not comply with the section cited above. Facility staff failed to provide the necessary care and supervision to R1 and R2 which allowed the residents to elope from the facility unassisted, which poses an immediate health and safety risk to residents in care.

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 and observations, the licensee did not comply with the section cited above, as the facility staff did not properly assist with R1’s self-administered medications per physician’s order which poses an immediate health and safety risk to residents in care.

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) 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, record review, and evidence from a credible witness, the Licensee did not comply with the section cited above in that three (3) staff members did not respect a resident's dignity which poses an immediate personal rights risk for persons in care.

87464(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 record review, the licensee did not comply with the above cited section, as facility accepted R1, who could not perform own glucose testing and facility did not have skilled professional to perform the glucose test which posed an immediate health risk to residents in care.

87628(a) Diabetes (a)The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing…, or has it administered by an appropriately skilled professional. This requirement is not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above as R1 could not perform own glucose testing and facility did not have skilled professional to perform the glucose test which posed an immediate health risk to resident in care.

Based on record review, the licensee did not comply with the section cited above in that 3 (three) out of 5 (five) staff did not have their 40 hours of initial training which poses a potential health, safety and personal rights risk to persons in care.

Based on record, the licensee did not comply with the section cited above in that 2 (two) out of 5 (five) staff did not have their 20 hours of annual training which poses a potential health, safety and personal rights risk to persons in care.

87405(a) Administrator Qualifications and Duties. All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section…This requirement was not met as evidenced by: The Licensee did not comply with the regulation cited above as the Administrator/ ED quit without proper notice, abandoning the facility which posed an immediate health and safety risk to residents in care.

§1569.652 (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued...resident’s estate, within 15 days after the personal property is removed.This requirement is not met as evidenced by: Based on interview and record review, the Licensee did not comply with the above cited section, as R1 passed away and all belongings were removed as of 12/30/2023 and refund has yet to be issued, which poses a potential personal rights risk to residents in care.

(a) Each licensee shall furnish to the licensing agency...(1) A written report shall be submitted to the licensing agency within 7 days of the occurrence... (D) Any incident which threatens the welfare, safety or health of any resident... This requirement is not met as evidenced by: Based on interviews and record review, facility's former Administrator was aware of the alleged sexual assault R1 made and failed to notify CCLD and follow mandated reporting requirements. This posed an immediate health and safety risk to residents in care.

87203 Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.This requirement is not met as evidenced by: Based on the investigation, observations and interviews, the licensee did not comply with the section cited above, as the door to exit the dining room to the lobby was locked and does not have delayed egress, which poses an immediate health and safety risk to residents in care.

Based on medication review, the licensee did not comply with the section cited above, as medications were not documented on the Centrally Stored Medications and Destruction Record for one out of two residents (R1), which poses a potential health and safety rights risk to persons in care.

87405 Administrator - Qualifications and Duties (a)... When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility... This requirement is not met as evidenced by:Based on interviews an administrator was not available for immediate guidance during incident on 4/8/2022 which poses an immediate health and saftey risk to persons in care.

87465(a)(1) Incidental Medical and Dental Care.(a) A plan for incidental medical and dental care shall be developed by each facility...(1) The licensee shall...assist in... medical...care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above. The Administrator and the Health Services Director did not take action to have R1 transported to a medical facility timely which poses an immediate health and safety risk to residents in care.

87466 Observation of the Resident... When changes... are observed... the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by:Based on interviews the licensee failed to notify R1's responsible party of R1's change in condition immediatley upon discovery, which poses an immediate health and safety risk to residents in care.

87411(a) Personnel Requirements. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on interviews and record review, licensee failed to ensure that the facility had an adequate number of staff to meet the residents needs, which poses an immediate health and safety risk to residents in care.

87615(a)(1) Prohibited Health Conditions. (a) Persons who require health services for or have a health condition including... those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as R1 was retained at this facility with unstageable pressure injuries, which poses an immediate health and safety risk to residents in care.

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities . 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 the investigation, the licensee did not comply with the section cited above regarding resident care needs and services for R1, R4, R5, and R6 which poses an immediate health and safety risk to residents in care.

1569.625( b)(1) Staff training; legislative findings. Staff members...who assist residents with personal activities of daily living to receive training. This training shall consist of 40 hours of training ….and shall be completed within the first four weeks of employment.This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above in eight out of twelve staff, which poses a potential health and safety risk to residents in care.

87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary, and in good repair at all times…This requirement is not met as evidenced by: Based on the investigation, and interviews, the licensee did not comply with the section cited above, as four out of 20 bedrooms were observed unclean, which poses a potential health and safety risk to residents in care.

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 was not met as evidenced by: Based on the investigation, and interviews, the licensee did not comply with the section cited above, as residents were not properly supervised, due to insufficient staff in numbers, which led to falls due to the delayed assistance, which poses an immediate personal rights risk to residents in care.

87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary, and in good repair at all times…This requirement is not met as evidenced by: Based on the investigation, and interviews, the licensee did not comply with the section cited above, as a housekeeping staff was not hired at the time of the visit, which poses an immediate health and safety risk to residents in care.

87303(i)(1)(B) Signal System- (i)Facilities shall have signal systems (1)All facilities licensed for 16 or more… shall have a signal system which shall: (B)Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. This requirement was not met as evidenced by: Based on the investigation, and interviews, the licensee did not comply with the section cited above, as the signal system is not functioning properly, which poses an immediate personal rights risk to residents in care.

87412(a) Personnel Records. The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee.This requirement is not met as evidenced by: Based on records review, the licensee did not comply in the section cited above for three out of thirteen staff members, as their files were incomplete, which poses a potential health and safety risk to residents in care.

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 three out of three residents (R1, R2, R3), which poses an immediate health and safety risk to residents in care.

87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary, and in good repair at all times…This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as one (1) out of three (3) delayed egress doors were inoperable, which poses an immediate health and safety risk to residents in care.

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 was not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as residents were not properly supervised which led to an elopement, which poses an immediate personal rights risk to residents in care.

87705(f)(2) Care of Persons with Dementia. (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as cleaning supplies and disinfectants. This requirement is not met as evidenced by:Based on observation, the licensee did not comply with the section cited above, as items were accessible to residents with dementia, which poses an immediate health and safety risk to residents in care.

87705(f)(2) Care of Persons with Dementia. (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:Based on observation, the licensee did not comply with the section cited above, as items were accessible to residents with dementia, which poses an immediate health and safety risk to residents in care.

87355(e)(2) 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: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by:Based on record review, the licensee did not comply with the section cited above, as S1 was not associated to the facility since 10/5/2021 and has continued to work at the facility, which poses an immediate health and safety risk to residents in care.