The Variel of Woodland Hills

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.