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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850058
Report Date: 09/06/2024
Date Signed: 09/06/2024 02:58:03 PM

Document Has Been Signed on 09/06/2024 02:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:IMPRESSIVE CARE, INC.FACILITY NUMBER:
195850058
ADMINISTRATOR/
DIRECTOR:		TAGARYAN, ARMINE ADRINEFACILITY TYPE:
740
ADDRESS:13302 ARMINTA STREETTELEPHONE:
(818) 517-6594
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 4DATE:
09/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:49 AM
MET WITH:Armine TagaryanTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:49 AM. LPA met with facility administrator Armine Tagaryan. Entrance interview conducted and the reason for the visit was explained.

Beginning at 09:52 AM, the LPA, along with facility 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:

KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured drawer to contain knives as well as a secured cabinet located under the sink which contained cleaning supplies.

BEDROOMS: There are three (3) bedrooms in the facility; one (1) is a dual occupancy room and two (2) are single occupancy rooms. All are designated for resident use. LPA and facility administrator toured all three (3) resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Three (3) resident beds were observed to contain full bed rails. Auditory alarms were observed on facility exits and all were functional at the time of the visit.

BATHROOMS: There are two (2) bathrooms at the facility. Both bathrooms are designated as shared resident bathrooms. All bathrooms were observed to be clean and in good repair and all were equipped with nonskid surfaces. Grab bars were observed in all showers and near all toilets, all were properly secured. The water temperature was measured between 121.6 and 124.7 degrees Fahrenheit, which is in compliance with regulation. Report Continued on LIC 809-C
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/06/2024 02:58 PM - It Cannot Be Edited


Created By: Trevor Byrne On 09/06/2024 at 01:17 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: IMPRESSIVE CARE, INC.
FACILITY NUMBER: 195850058

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

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 as the last quarterly disaster drill was conducted on 04/08/2024 which poses a potential health and safety risk to persons in care.
POC Due Date: 09/13/2024
Plan of Correction
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Administrator will conduct an emergency disaster drill and will submit proof to CCL no later than POC due date.
Type B
Section Cited
CCR
87705(c)(6)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals.

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. One (1) out of four (4) residents were not reappraised after a change in condition which poses a potential health and safety risk to persons in care.
POC Due Date: 09/13/2024
Plan of Correction
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Administrator will have the identified resident reappraised by their physician. Administrator will subimt an updated physician's report for the identified resident to CCL no later than 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:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024


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Document Has Been Signed on 09/06/2024 02:58 PM - It Cannot Be Edited


Created By: Trevor Byrne On 09/06/2024 at 01:26 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: IMPRESSIVE CARE, INC.
FACILITY NUMBER: 195850058

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above while testing the fire alarms the fire door separating resident rooms from the front of the facility failed to close. Additionally, fire extinguishers throughout the facility were not serviced annually and were last serviced on 08/31/2023 which poses an immediate safety risk to persons in care.
POC Due Date: 09/07/2024
Plan of Correction
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Administrator will submit proof of the fire door functioning appropriately and proof that fire extinguishers have been serviced or replaced to CCL no later than POC due date.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024


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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: IMPRESSIVE CARE, INC.
FACILITY NUMBER: 195850058
VISIT DATE: 09/06/2024
NARRATIVE
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COMMON AREAS/GARAGE: This includes the living room. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contains a dining table with chairs and recliners for resident use. LPA observed a hallway closet to contain extra linens and craft supplies. The Garage is attached to a facility located at the front of the property (Noble Care: 197608760). LPA observed the garage to contain a washer and dryer, emergency water supplies, and extra care supplies.

OUTDOOR SPACE: The facility has two (2) emergency exit gates located in the front yard; LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. The backyard contains one (1) secured shed that was observed to contain cleaning supplies. LPA observed an appropriately fenced off pool that was inaccessible to residents in care.

RECORD REVIEW: Record review began at 10:58 AM. 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, TB tests, consent forms, and personal rights. Three (3) staff files were reviewed. All staff files contained the required documents and trainings. Four (4) resident files were reviewed. One (1) resident file reviewed revealed that the resident had not been reappraised by their physician following a change in condition. All other resident files contained all required documentation.

MEDICATION REVIEW: Medication review began at 12:08 PM. Medications are stored centrally and securely in a cabinet in the living room. Medications for two (2) residents were observed. All medications observed were documented appropriately on their centrally stored medication and destruction record sheets. No deficiencies were observed during medication review.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA 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 drills are to be conducted quarterly; the facility’s last emergency disaster drill was conducted on 04/08/2024 which is not in compliance with regulations. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan were reviewed/updated on 09/06/2024 by the facility’s administrator. Report Continued on LIC 809-C
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: IMPRESSIVE CARE, INC.
FACILITY NUMBER: 195850058
VISIT DATE: 09/06/2024
NARRATIVE
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INTERVIEWS: LPA interviewed one (1) staff and three (3) residents. All residents interviewed stated that the staff treat them well and are attentive to their needs. No residents interviewed had concerns with the facility. The staff member interviewed was knowledgeable on their role and responsibilities, resident rights, the different forms of abuse and the appropriate reporting procedures for suspected abuse. The staff interview was conducted with the assistance of the administrator acting as a translator.

Fire extinguishers were observed to be last serviced on 08/31/2023 which is outside of the annual requirement. Smoke detectors and carbon monoxide detectors were tested at 10:50 AM and were functional at the time of the visit. During the test LPA observed the fire door, separating resident rooms from the rest of the facility, to fail to close which poses an immediate health and safety risk to residents in care. This is a zero-tolerance violation and an immediate civil penalty of $500 is being assessed.

During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and liability insurance.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies and civil penalty were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC809 (FAS) - (06/04)
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