Walnut Garden III

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a required annual visit at 1:32PM. The LPA met with the Licensee Izhak Illouz and Administrator Arlene Ceballos. Entrance interview conducted. Beginning at 1:37PM, the LPA and Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: The LPA observed knives and cleaning supplies secured. Kitchen appliances were clean and in operable condition. The facility had a supply of perishable and non-perishable food, as well as emergency food. Food in the refrigerator and freezer were observed to be properly stored with labels and dates. Medications were stored in a locked cabinet. The kitchen had laundry machines that were in good condition. COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. Required postings were located on the entryway wall. The facility maintained a comfortable temperature throughout the visit. Night lights were observed throughout the facility. Report Continued on LIC 809-C BEDROOMS/RESTROOMS: There were seven (7) total bedrooms: six (6) private resident bedrooms and one (1) locked staff bedroom. Bedrooms #3, #5, and #6 have direct exits to the outside, and Bedroom #5 is cleared for one (1) bedridden resident. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Extra linens were stored in a dresser located in the hallway. There were six (6) total restrooms in the facility: five (5) attached private resident restrooms and one (1) common restroom located in the common area. Restrooms were clean, sanitary, and in operating condition with grab bars and non-slip surfaces. All restrooms were sufficiently stocked with soap, paper products, and displayed hand washing signs. Sink cabinets were locked and contained hygiene products. Hot water was tested and measured between 111.6 degrees F and 117 degrees F, which is within the required range per regulation. OUTDOOR AREA: The surrounding grounds had multiple shaded patio areas equipped with furniture in good condition for resident and visitor use. There was one (1) emergency exit located on one side of the facility with a self-latching mechanism. The opposite side of the property had an Additional Dwelling Unit (ADU) that was occupied by tenants unrelated to the facility. The side gate that led to the ADU was locked. All exits and passageways were free of obstructions. The LPA observed one (1) locked shed in the backyard that contained general storage, facility supplies, and emergency water. RECORDS: Record review began at 1:58PM. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, and consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order. Report Continued on LIC 809-C INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPA reviewed the facility's infection control plan and emergency disaster plan. Both documents were observed to be complete and reviewed annually as required. Emergency disaster drills are conducted quarterly, with the last documented drill on 07/02/2026. Smoke and carbon monoxide detectors were tested at 2:45PM and were operational. Fire extinguishers were observed throughout the facility and was last serviced on 01/05/2026. MEDICATIONS: Medication review began at 12:24PM. Medications were centrally stored and kept inaccessible in the kitchen. Medications were observed for two (2) residents. Medications were labeled and checked for expiration dates and were properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Jul 9, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a required annual visit at 10:37AM. The LPA met with the Licensee Izhak Illouz and Administrator Arlene Ceballos. Entrance interview conducted. Beginning at 10:42AM, the LPA and Licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and facility is in compliance with Title 22 Regulations. The facility is a single story residential home. The following was observed: BEDROOMS/RESTROOMS: There were seven (7) total bedrooms; six (6) private resident bedrooms and one (1) locked staff bedroom. Bedrooms #3, #5, and #6 have direct exits to the outside, and Bedroom #5 is cleared for one (1) bedridden resident. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Extra linens were stored in a dresser located in the hallway. There were six (6) total restrooms in the facility: five (5) attached private resident restrooms and one (1) common restroom located in the common area. Restrooms were clean, sanitary, and in operating condition with grab bars and non-slip surfaces. All restrooms were sufficiently stocked with soap, paper products, and displayed hand washing signs. Sink cabinets were locked and contained hygiene products. Hot water was tested and measured between 114.4 degrees F and 118.4 degrees F, which is within the required range per regulation. Report Continued on LIC 809-C COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. Required postings were located on the entryway wall. The facility maintained a comfortable temperature throughout the visit. During the visit, LPA observed residents participating in their weekly Music Class and the facility stored extra activities in the entertainment center. Night lights and exit signs were observed throughout the facility. Fire extinguishers were observed throughout the facility and was last serviced on 01/03/2025. OUTDOOR AREA: The surrounding grounds had multiple shaded patio areas equipped with furniture in good condition for resident and visitor use. There was one (1) emergency exit located on one side of the facility with a self-latching mechanism. The opposite side of the property had an Additional Dwelling Unit (ADU) that was occupied by residents unrelated to the facility. The side gate that led to the ADU was locked. All exits and passageways were free of obstructions. The LPA observed one (1) locked shed in the backyard that contained general storage, facility supplies, and emergency water. KITCHEN: The LPA observed knives stored inaccessible in a locked drawer. Cleaning supplies were stored inaccessible and locked under the sink. Kitchen appliances were clean and in operable condition. The facility had a supply of perishable and non-perishable food, as well as emergency food. Food in the refrigerator and freezer were observed to be properly stored with labels and dates. Medications were stored in a locked cabinet. The kitchen had laundry machines that were in good condition. RECORDS: Record review began at 11:03AM. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, and consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order. Report Continued on LIC 809-C INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPA reviewed the facility's infection control plan and emergency disaster plan. Both documents were observed to be complete and reviewed annually as required. Emergency disaster drills are conducted quarterly, with the last documented drill on 04/25/2025. Smoke and carbon monoxide detectors were tested at 12:13PM and were operational. Additionally, the facility does monthly smoke/fire alarm checks and replaces batteries if necessary. MEDICATIONS: Medication review began at 12:16PM. Medications were centrally stored and kept inaccessible in the kitchen. Medications were observed for two (2) residents. Medications were labeled and checked for expiration dates and were properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Jul 8, 2025

Allegation investigated: Staff mishandled a resident while in care - (Resident #1 (R1) sustained a fractured wrist, while under facility care) Facility staff failed to provide timely medical care for Resident #1 (R1).

This reports supersedes report issued on 04/03/2024. Licensing Program Analyst (LPA) Valeria Conway conducted a subsequent complaint visit to deliver final findings for the above allegations. During today’s visit, LPA Conway met with Administrator Izhak Illouz and Licensee Arlene Ceballos and explained the reason for the visit. On 03/28/2024, the Woodland Hills North Adult and Senior Care office received a complaint regarding two allegations of Lack of Care and Supervision. The complaint alleged Resident #1 (R1) sustained a fractured wrist and the facility staff failed to seek timely medical attention. The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Olivia Spindola. Continued on LIC 9099-C Unsubstantiated This reports supersedes report issued on 04/03/2024. Continued from LIC 9099 On 04/03/2024, from 10:15 a.m. to 5:30 p.m., LPA Conway conducted an unannounced 10-day complaint visit. LPA Conway met with administrator Izhak Illouz and assistant administrator Arlene Ceballos and explained the reason for the visit. From 11:10 a.m. to 12:54 p.m., the LPA conducted a tour of the physical plant, reviewed facility files, obtained copies of pertinent documentation relevant to the investigation, and conducted interviews with facility staff, administrator, and residents. Investigator Spindola conducted interviews on 04/24/2024, at approximately 11:00 a.m., with R1’s resident representative; on 05/14/2024, at approximately 1:00 p.m., with facility assistant administrator; on 06/04/2024, at approximately 9:00 a.m., attempted interviews with staff, left message; on 07/03/2024, from approximately 2:45 p.m. to 4:00 p.m., with administrator, staff, resident and R1’s healthcare case consultant. In addition, the investigator reviewed Encino Hospital Medical Center medical records, radiology results from Professional Imaging Network, and facility file documents related to the investigation. According to the review of the Encino Hospital Medical Center medical records, R1 was brought in by ambulance on 03/27/2024 after a ground level fall at the facility that morning. The records noted R1 had a history of hypothyroidism, hypertension, rheumatoid arthritis, advanced dementia with psychotic feature, poor mobility, hypercoagulable state, significant dyslipidemia, and chronic low blood pressure. A deformity was noted, and an x-ray revealed left wrist fracture. R1’s resident representative chose not to proceed with surgery and preferred conservative management. Continued on LIC 9099-C This reports supersedes report issued on 04/03/2024. Continued from LIC 9099-C The Department’s investigation revealed that on 03/27/2024, at approximately 10:00 a.m., Resident #1 (R1) sustained a fall in R1’s bathroom. The facility staff attended to R1 and contacted the assistant administrator who then contacted R1’s healthcare case consultant who in turn notified R1’s resident representative, who requested R1 have x-rays taken of R1’s left wrist at the facility, instead of having R1 hospitalized, if it was not necessary. The x-ray results revealed that R1 sustained a fractured left wrist. On 03/27/2024, during the evening hours, R1’s resident representative then gave approval to the facility staff to send R1 to the hospital for medical care. R1’s resident representative did not have any concerns regarding the care R1 receives at the facility. Based on the above information, the Department did not find sufficient evidence of neglect/lack of care and supervision, therefore, the allegations “Neglect/Lack of Care and Supervision: Resident #1 (R1) sustained a fractured wrist, while under facility care” and “Neglect/Lack of Care and Supervision: Facility staff failed to provide timely medical care for Resident #1 (R1)” are deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issued.the state’s words, verbatim · CDSS document, Jan 14, 2025 · control 29-AS-20240328095338

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Valeria Conway conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20240328095338). The purpose of the visit is to issue citations for deficiencies observed during the initial complaint investigation unrelated to the complaint. During today’s visit, LPA met with Administrator Izhak Illouz and Licensee Arlene Ceballos and explained the reason for the visit. During initial visit, LPA conducted a tour of the physical plant. At 10:28 a.m., LPA requested to review facility files, employee’s roster and residents’ files. Additionally, at 10:45 a.m., LPA obtained and reviewed copies of pertinent documentation relevant to the investigation. Between 11:20 a.m. and 12:54 p.m., LPA conducted interviews with facility staff, Administrator, and residents. During today’s visit, the LPA conducted a brief physical plant tour, to ensure there are no health and safety concerns. During the Department’s investigation, the following deficiencies were observed: A review of the staff schedule for March and April 2024 was conducted to assess the allocation and coverage of staff. The schedule was organized into three columns. Each column detailed the coverage for three of the facilities operated by the Licensee, however, shift schedule was not noted. Interviews with the administrator indicate that the facility provides appropriate care for residents during the night shift. According to the administrator, staff conducts constant checks on residents throughout the night. Continued on LIC 9099-C Continued from LIC 9099-C The facility did not submit a Special Incident Report (SIR) to Community Care Licensing (CCL) to notify that Resident #1 (R1) sustained a fall resulting in a fractured wrist on 03/27/2024. Licensee did not update R1’s appraisal needs and services plan to document R1’s change of condition which included behavioral issues and aggression which required medication adjustment. A review of R1’s Physician Report revealed the report was not complete as the physician’s signature and date were missing and the section for authorization for release of medical information was blank. During the initial visit on 04/03/2024, LPA observations and record reviewed revealed that Staff #1 (S1) currently working at the facility however S1 is not fingerprint cleared nor associated to the facility. Furthermore, a review of Guardian system and the staff roster revealed that Staff #2 (S2) is fingerprinted but not associated to the above facility. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 809-D) Exit interview conducted. Citation issued. A Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, Jan 14, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Apr 12, 2024

87355: 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 requierment is not met as evidence by: Based on records reviewed staff #1 has been working at the facility but does not have backround clearance and it is not associated to the facilit, which poses and immediate safety risk to residents in carethe state’s words, verbatim · CDSS document, Jan 14, 2025

Plan of correction: Administratorwill have S1 finguerprinted and associated to the facility and send prof to LPA.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87411(a) · Plan of correction due date: Jan 17, 2025

Personnel Requirements - General (a) 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 records review and interviews, the licensee did not comply with the section cited above. There is no staff coverage from 7:00pm to 7:00am, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 14, 2025

Plan of correction: The licensee will submit a Personnel Report form LIC500 which reflects 24/7 adequate staff coverage. Also include the administrator’s and designated substitute’s days/hours at the facility. Submit proof to CCL by POC due date

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(b) · Plan of correction due date: Jan 28, 2025

87463(b) Reappraisals (b) The reappraisal shall document significant changes in the resident's physical, ..., including those required to be documented as specified in Section 87466, Observation of the Resident. This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above. Licensee did not update R1’s appraisal needs and services plan to document R1’s change of condition which included behavioral issues and aggression which required medication adjustment, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 14, 2025

Plan of correction: The licensee will submit a plan describing how you will ensure the resident appraisals are updated when there is a change of condition to reflect the current needs of the resident. Submit proof to CCL by POC due date

From the deficiency page — Deficiency type: Type B · Section cited: CCR87458(a) · Plan of correction due date: Jan 28, 2025

87458(a) Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional ... kept in the resident's record. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above. R1’s medical assessment was missing physician signature and date, and the section for authorization for release of medical information was blank, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 14, 2025

Plan of correction: The licensee will submit a plan how you will ensure resident documents are complete, including signatures and dates. Submit proof to CCL by POC due date

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: Jan 28, 2025

87211(a)(1)(B) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted to the licensing agency and to the person responsible... events specified in (A) through (D) below….. (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above. Licensee did not submit an incident report when R1 fell and fractured wrist, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 14, 2025

Plan of correction: The licensee will submit a plan describing how you will comply with reporting requirements. Submit proof to CCL by POC due date

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Angela Barutyan, Kelly Dulek, and Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 9:49AM. LPAs met with Licensee/Administrator Izhak Illouz. Entrance interview conducted. Beginning at 9:54AM, the LPAs, along with Licensee/Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: Fire extinguishers are fully charged and recently serviced on 02/06/2024. At 10:15AM, LPAs observed the side gate to be locked at the time of the visit which poses a fire clearance concern. Hardwired combination smoke and carbon monoxide detectors were tested at 10:55AM and all were functional at the time of the visit. LPAs observed a fire door separating the living room from resident bedrooms which failed to self-close at the time the test was conducted. BEDROOMS: There are 7 (seven) total bedrooms in the facility; 6 (six) are designated as private resident rooms and 1 (one) is utilized as a staff room. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Staff room was observed to be locked. BATHROOMS: There are 6 (six) bathrooms for resident use. 1 (one) is designated for shared resident use and the other 5 (are) are private resident restrooms. Restrooms were observed to contain nonskid mats. Grab bars were observed in the bathrooms. The water temperature was measured in all resident bathrooms and measured between 111.7 and 118.8 degrees Fahrenheit, which is within the required range. Room #7 belonging to resident #1 (R1) was observed to have missing grab bars in the shower and by the toilet. Staff placed temporary suction grab bars which fell off at the time of the visit. COMMON AREAS: This includes the living room and dining room areas. LPAs observed common area to be clean and properly furnished at the time of the visit. Report Continued on LIC 809-C Exit doors contain alarms and were functional at the time of the visit. OUTDOOR SPACE: The backyard has a covered patio area with patio furniture including tables and chairs for resident use. All passageways were observed to be clear. There were no bodies of water on the premises. An outdoor shed containing emergency water supply was observed to be locked and inaccessible to residents. KITCHEN/GARAGE: Kitchen was observed to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of seven (7) days non-perishable and two (2) days perishable food. Knife drawer was observed to have a non-functioning lock, however, no knives were observed to be in the drawer at the time of the visit. Cleaning supplies are located in a locked under-sink cabinet. Washer and dryer were observed to be next to the refrigerator. Medications were observed to be in a locked kitchen cabinet. The garage on the property has been converted to a residential unit with a separate address which is not attached to the house. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPAs reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted quarterly, with the last drill conducted on 04/05/2024. RECORD REVIEW: Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. 6 (six) staff files observed contained all documents. MEDICATION REVIEW: Medications for 2 (two) residents were observed. All medications observed were labeled, stored, and properly documented at the time of the visit. INTERVIEWS: During today's visit, LPAs interviewed 2 (two) staff and 2 (two) residents. During today's visit, LPAs obtained a copy of the facility's liability insurance. Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Civil penalty were issued in the amount of $500. Administrator was informed that failure to correct deficiencies may result in additional civil penalties. Exit interview conducted, report issued, and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 10, 2024

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.