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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209266
Report Date: 11/07/2023
Date Signed: 11/08/2023 08:28:06 AM

Document Has Been Signed on 11/08/2023 08:28 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:HEAVENLY CASTLE CARE INCFACILITY NUMBER:
157209266
ADMINISTRATOR:NSHANYAN, HASMIKFACILITY TYPE:
740
ADDRESS:1651 WHITE ROCK RDTELEPHONE:
(310) 993-2447
CITY:FRAZIER PARKSTATE: CAZIP CODE:
93225
CAPACITY: 6CENSUS: 6DATE:
11/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:21 AM
MET WITH:Administrator Hasmik NshanyanTIME COMPLETED:
04:15 PM
NARRATIVE
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LPA Shawna Doucette arrived at the facility unannounced to conduct an annual inspection. LPA was granted entry by Staff Vachagan Margaryan and Staff Arusyak Ayvazyan. LPA explained the purpose of the visit and staff contacted Administrator Hasmik Nshanyan who responded to the facility to assist with the visit.

A tour of the facility was conducted with the Administrator. The residence was set at 68 F temperature and free of passageway obstructions inside and outside.

Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. Medications were stored in a locked cabinet in the kitchen. Cleaning supplies were locked in the laundry room. Smoke detectors and carbon monoxide detectors were checked and operating. Fire drill was last conducted 10/18/23. LPA checked water temperature which measured at 111.2 F.

There was outdoor seating for the residents.

Resident, medication and staff records were reviewed. LPA observed a medication error for R1. R1 ran out of all medications however the start date was 10/16/23 for 30 pills which indicates R1 should have 7 pills remaining. R1 was out of PRN medications and facility did not have a log for the PRN medication. Current first aid and CPR were reviewed.

R2 and R3 did not have Hospice Care Plans.

Staff records indicate Staff Arusyak Ayvazyan was not cleared to be working in the facility.

Refer to 809d for deficiencies. Civil Penalty was issued.

A copy of this report with plan of correction and appeal rights were provided to the Administrator.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 8
Document Has Been Signed on 11/08/2023 08:28 AM - It Cannot Be Edited


Created By: Shawna Doucette On 11/07/2023 at 02:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: HEAVENLY CASTLE CARE INC
FACILITY NUMBER: 157209266

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.17(c)(1)(A)
Licensing
(c)(1)(A) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in a facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in Staff Arusyak Ayvazyan not being fingerprint cleared prior to working in the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2023
Plan of Correction
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Licensee agrees to not have employees work at the facility until fingerprint cleared. Staff was immediately removed from the facility. POC cleared during visit. Civil Penalty issued.
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in R1 running out of medications 7 days before the medications should have run out, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2023
Plan of Correction
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Licensee agrees to conduct a medication training conducted by a skilled professional and submit agenda and sign in sheet by POC due 11/17/23.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Shawna Doucette
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023


LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 11/08/2023 08:28 AM - It Cannot Be Edited


Created By: Shawna Doucette On 11/07/2023 at 02:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: HEAVENLY CASTLE CARE INC
FACILITY NUMBER: 157209266

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(b)
Incidental Medical and Dental Care Services
(b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in R1 ran out of PRN medications and medications were not refilled, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2023
Plan of Correction
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Licensee agrees to conduct training by a skilled professional on PRN medications and submit agenda and staff trained by POC due date 11/17/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Shawna Doucette
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 11/08/2023 08:28 AM - It Cannot Be Edited


Created By: Shawna Doucette On 11/07/2023 at 02:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: HEAVENLY CASTLE CARE INC
FACILITY NUMBER: 157209266

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in not having health screenings for staff, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2023
Plan of Correction
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Licensee agrees to submit staff health screenings by POC due date 11/17/23.
Type B
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in R1's PRN was not logged date or time which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2023
Plan of Correction
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Licensee agrees to submit a written statement of the understanding of this regulation and how it will be met by POC due date 11/17/23.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Shawna Doucette
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 11/08/2023 08:28 AM - It Cannot Be Edited


Created By: Shawna Doucette On 11/07/2023 at 02:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: HEAVENLY CASTLE CARE INC
FACILITY NUMBER: 157209266

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in not having a written order from a physican on a prescription blank for all residents in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2023
Plan of Correction
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Licensee agrees to submit a written statement on the understanding of this regulation and how this regulation will be met by POC due
Type B
Section Cited
CCR
87633(b)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in not having a hospice care plan for R2 and R3 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2023
Plan of Correction
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Licensee agrees to submit copies of R2 and R3's hospice care plans by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Shawna Doucette
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023


LIC809 (FAS) - (06/04)
Page: 5 of 8