Heritage of Northridge

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with Administrator Maryann Mijares and explained the reason for the visit. At approximately 12:50 pm, with the assistance of the Administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are interconnected and battery-operated. There is a carbon monoxide detector that functions properly installed in the kitchen area. The fire extinguisher is located between residents room. The charge date is October 14, 2024. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Bedrooms: There were four (4) bedrooms designated for residents' use. Currently, Room 2 is vacant. All bedrooms, in use by residents, were properly furnished with appropriate beddings and linens with sufficient lighting.Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 106.7 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathroom during the inspection. Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. The dining room table is large enough to sit the capacity of the facility. Seating such as couches where in good repair and sit the capacity of the facility. Properly labeled medications were locked in one of the hallway cabinets. Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The gates at the sides of the home was checked to ensure no locks were installed, and that exits and passageways were clear for emergency evacuation. (Continue on 809C) Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms. Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Medications: Medication and Medication Records were review for proper documentation. Temperature: Facility maintains a comfortable temperature of 75 degrees Fahrenheit Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issuedthe state’s words, verbatim · CDSS document, Sep 29, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Gary Tan met with Administrator Maryann Mijares for a One (1) Year Required visit for this facility. LPA informed the Administrator the purpose of the visit. There is only one entrance being utilized at the facility. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation and Infection Plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted indoors. Hand washing coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room. A tour of the physical plant was conducted with Ms. Mijares at 3:15 PM. The facility is a single storey building with four (4) bedrooms and three (3) bathrooms currently occupying five (5) residents. The facility is fire cleared for six (6) non-ambulatory residents, one (1) of which may be bedridden on Room 1. Hospice waiver for two (2) residents. Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, the following was noted: Living and dining room furniture were also checked. The living room is neat and clean along with dining area. The facility maintains a comfortable temperature at 74°F. The smoke detectors are hardwired and interconnected and observed to be operational. The fire extinguishers were filled and last inspected on 10/14/24. The facility is equipped with sprinkler system. There is a carbon monoxide detector installed at the facility. (continued on LIC 809-C) The backyard of the facility has outdoor furniture, with a covered shaded area for clients. The front and backyard passageways were clear of any obstruction. There is no body of water in the facility. The backyard has a twenty (20) footer trailer being used as miscellaneous storage. The garage was converted into an additional dwelling unit (ADU) and currently being used as staff house. There is no access to the staff house from inside the facility. Laundry area is located adjacent to the kitchen. Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Cleaning supplies including detergents and pesticides and other toxins are stored in the locked laundry. Knives and sharps are observed to be kept in a locked drawer in the kitchen. The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Clients have sufficient amounts of personal hygiene product which is provided by the licensee. The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. The hot water temperature measured at a range of 114.9°F to 117.8°F. Towels and washcloths are not shared. There is enough clean linen available in stock at the linen cabinet. Medications: LPA observed medication in the kitchen cabinet to be locked and inaccessible to residents. Medications are listed on the centrally stored medication and destruction record. First aids kits have complete tools and supplies. Client records: Client records are reviewed and appeared to be complete and updated. Staff records: LPA conducted a complete file review of staff record. Staff records appeared to be complete and updated. Disaster drill was last conducted on 10/28/2024. Required posting are observed to be complete and current and displayed properly at the facility. Exit interview conducted and copy of this report issued.the state’s words, verbatim · CDSS document, Nov 21, 2024

Allegation investigated: Due to lack of supervision, attempted physical assault on resident by an unknown person

This is an amended report of the prior investigation report delivered on 01/29/24. The amended report includes additional information regarding the investigation. The determination of the allegation remains Unsubstantiated. Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced complaint visit to investigate the above stated allegation. LPA was greeted by S1. Shortly after the Administrator arrived at the facility and explained the reason for the visit. At 9:30 am, LPA requested resident and staff roster. At approximately 09:45 am, LPA conducted a physical plant tour, to ensure health and safety of the residents. Allegation: Due to lack of supervision, attempted physical assault on resident by an unknown person It was alleged that on 1/18/2024 a male attempted to physically assault R1. At 10:15 Am today, LPA requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s report, Appraisal Needs and Services Plan, Staff Schedule, etc., relevant to the investigation. Between 11:00am – 12:10 PM, LPA interviewed Administrator and one (1) out of 2 staff members and four (4) out of four (4) residents. (Continue LIC 9099C) Unsubstantiated The administrator denied the allegation. Interview with the Administrator revealed that there was only a female caregiver on the night shift of 1/18/2024. Administrator indicated that R1 has a history of hallucinations, predominately at night. Information obtained during interviews with 2 out of 4 residents did not corroborate the allegation. Interview with S1 revealed that R1 hallucinates every time R1 is alone in the room even in the daytime. Per S1 there were no visitors in the facility on 1/18/24. During the visit, LPA conducted an interview with R1. Immediately after the interview was concluded, LPA witnessed R1 having an apparent hallucination of being physically assaulted while R1 was alone in R1’s room. Information obtained during an interview with R1’s former conservator (W1) indicated that R1 has a history of hallucinations, similar to the allegation. W1 advised that W1 visits R1 weekly and has observed that R1 is well cared for, and R1’s physical appearance and health appear to have improved during R1’s residence at the facility. W1 also indicated that R1’s Family Member (W2) was an unreliable source of information for the purpose of this investigation. Based on interviews and record reviews there is insufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Jan 29, 2024 · control 31-AS-20240123154443

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Mariana Agban conducted unannounced visit to this facility in conjunction with a complaint control 31-AS-20240123154443. During the physical plant tour, LPA observed sharp objects are not locked in the lock box. Administrator locked sharp objects immediately. LPA also observed a gallon of roof paint in the hallway. Administrator stated that there was a leak on the roof and the painter had left the paint on the hallway entrance. LPA reminded Administrator that paint should be stored inaccessible to residents with dementia. Staff immediately locked the paint. Exit interview conducted and deficiencies cited and copy of this report deliveredthe state’s words, verbatim · CDSS document, Jan 29, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(1) · Plan of correction due date: Jan 29, 2024

87705(f)(1) Care of persons with Dementia The following shall be stored inaccessible to residents with dementia:(1)Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). Based on observation, the licensee did not comply with the section cited above. LPA observed sharp objects drawer unlocked. This poses/posed an immedate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 29, 2024

Plan of correction: Administrator locked immediately the drawer.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(f)(2) · Plan of correction due date: Jan 29, 2024

Care of persons with Dementia The following shall be stored inaccessible to residents with dementia:Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. Based on observation, the licensee did not comply with the section cited above. LPA observed a gallon of roof paint in the entry hallway. This poses/posed an immedate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 29, 2024

Plan of correction: Staff locked immediately locked the gallon of piant.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with Administrator Maryann Mijares and explained the reason for the visit. At approximately 10:40 am, with the assistance of staff, LPA took a tour of the physical plant to ensure the health and safety of the residents are protected and that the physical plant complies with Title 22 Regulations. Required postings were observed in the entry area. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked box in the kitchen. Properly labeled medications were locked in one cabinets of the living room cabinet. The fire extinguisher is located in the hallway with service date of September, 2023. Bedrooms: There were four (4) bedrooms designated for residents' use. Two (2) bedrooms are designated for private use, and two (2) room is shared. All four bedrooms, in use by residents, were properly furnished with appropriate bedding and linens with sufficient lighting. Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 102.8 and 103.6 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathroom during the inspection. Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. Laundry Area: The laundry area is located near by the living room. Laundry cabinet was locked and thus laundry detergents were inaccessible to residents. Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms. Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and in compliance with licensing forms. Medications: Medication and Medication Records were reviewed for proper documentation. Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.the state’s words, verbatim · CDSS document, Jan 10, 2024