Facility Evaluation Report

At approximately 1:30 p.m. on 06/18/25 Licensing Program Analyst (LPA) Nicholas Reed initiated an unannounced case management visit at the Woodland Hills-South Regional Office. LPA met with the licensee and disclosed the reason for the visit.

The purpose of today’s case management visit was to issue deficiencies previously noted at the facility during complaint investigations on 06/05/25 and 06/17/25 of complaints # 31-AS-20250602111246 and # 31-AS-20250616164325. During the investigations, LPA requested records for all residents. Record review at 10:30 a.m. on 06/17/25 revealed that Resident #1 (R1) was admitted without a medical assessment within the past twelve (12) months.

R1 also did not have a preplacement appraisal, admission agreement, care plan. inventory list, or signed personal rights form. R1 was admitted with a G-tube and a catheter and was receiving hospice services, yet the licensee admitted at 1:20 p.m. on 06/18/25 that the facility did not retain R1’s hospice paperwork. R1 was readmitted to the facility around 06/11/25 with a Total Parenteral Nutrition (TPN) line and a catheter but no home health services or documents.

Resident #2 (R2) had a medical assessment which was older than twelve (12) months.

The facility did not update the care plan for Resident #3 (R3) within the past twelve (12) months.

Resident #4 (R4) signed up for a private room in their admission agreement. R4 also did not have signed consent forms, tuberculosis results, inventory sheet, or signed personal rights form. Around 10:00 a.m. on 06/17/25 and at 1:00 p.m. on 06/05/25, LPA observed R4 was in a shared room with R3. Additionally, R3 and R4 both noted that they did not enjoy living with one another in the same room.