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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850075
Report Date: 11/13/2023
Date Signed: 11/13/2023 06:38:13 PM

Document Has Been Signed on 11/13/2023 06:38 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:A-1 BOARDING CAREFACILITY NUMBER:
195850075
ADMINISTRATOR:HOVHANNES ISPIRYANFACILITY TYPE:
740
ADDRESS:6511 BONNER AVE.TELEPHONE:
(818) 691-3146
CITY:N. HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 6CENSUS: 4DATE:
11/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Erna Gevorgyan, Designated StaffTIME COMPLETED:
06:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Yee conducted an unannounced required Annual Inspection visit using the complete CARE Inspection Tool and was let into the home by staff. Erna Gevorgyan, Designated Staff, was contacted via telephone and she arrived at the facility to conduct the visit at 10:52am to conduct the visit. Hovhannes Ispiryan, Administrator is out of town.

The facility is a single storey family home consisting of a living room, a dining room, a kitchen, 4 bedrooms, 2 private bathrooms and a common bathroom. The facility is fire cleared for 1 AMBULATORY, 4 NON-AMBULATORY and 1 BEDRIDDEN resident. Located at the back of the facility is a alternate dwelling unit(ADU) that was recently added. Permits were obtained on 3/23/22 and the ADU was approved for occupancy on 6/30/23. Copies of the permits were obtained today and a copy of the Certificate of Occupancy will be provided to the Department as soon as the Licensee receives a copy. The address assigned to the ADU is 6509 Bonner Avenue and is currently occupied by the Licensee and his family.

Due to time constraints, the following domains were reviewed on today's visit:
Infection Control, Operational Requirements, Staffing, Personnel Records: Training, Resident Records: Incident Reports, Resident Rights: Information, Planned Activities, Food Service, Incidental Medical and Dental, Disaster Preparedness, Residents with Special Health Needs. The Physical Plant and Environmental Safety Domain will be completed on a return visit.

During today visit, all the following files were reviewed: 6 staff files, 4 resident files, Infection Control Plan, Emergency Disaster Plan and the Plan of Operations.

Continued on LIC809-C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE: DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2023
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 5
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: A-1 BOARDING CARE
FACILITY NUMBER: 195850075
VISIT DATE: 11/13/2023
NARRATIVE
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Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Any citations not issued on today's visit will be issued on a return visit.

Exit interview was conducted, APPEALS RIGHTS, discussed and a copy was given
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 11/13/2023 06:38 PM - It Cannot Be Edited


Created By: Christine Yee On 11/13/2023 at 05:34 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: A-1 BOARDING CARE
FACILITY NUMBER: 195850075

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

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 per review of staff files, the Administrator and Staff #6's health screens do not have evidence or results that a TB test was completed, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/20/2023
Plan of Correction
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The Administrator and Staff #6 needs to complete a TB test or provide evidence that a TB test was conducted and the results of the test is obtained and maintained in their files by POC date - 11/20/23

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:Kristin Heffernan
LICENSING EVALUATOR NAME:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 11/13/2023 06:38 PM - It Cannot Be Edited


Created By: Christine Yee On 11/13/2023 at 05:34 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: A-1 BOARDING CARE
FACILITY NUMBER: 195850075

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:

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 per review of resident files, all four residents do not have completed Appraisal/Needs and Services plan in their files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/20/2023
Plan of Correction
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The Licensee will ensure that all resident files contain a completed Appraisal/Needs and Services Plan to ensure that their needs are being met and addressed. Provide evidence that an Appraisal/Needs and Services Plan has been completed by 11/20/23
Type B
Section Cited
HSC
1569.319(a)
Regulations
(a) A licensee of a facility that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for resident use.

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 as the facility has not provided the resident in care with any dedicated internet access device and does not have a plan to ensure that all residents in care have access to its use in during reasonable hours, poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/20/2023
Plan of Correction
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The Licensee will provide the residents with a dedicated internet device that can support real-time interactive applications, is equipped with videoconferencing technology, including a microphone and camera functions. Licensee will also pult together a plan that will allow all residents access to the use of the device within reasonable hours by 11/20/23
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:Kristin Heffernan
LICENSING EVALUATOR NAME:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 11/13/2023 06:38 PM - It Cannot Be Edited


Created By: Christine Yee On 11/13/2023 at 06:01 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: A-1 BOARDING CARE
FACILITY NUMBER: 195850075

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(b)
87465 Incidental Medical and Dental Care:(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 record review and interview , the licensee did not comply with the section cited above, per information provided for Resident #2 and Resident #3. They do not have PRN Authorization Letters on File for Arthritis Pain for Resident #2 and Tylenol and Benzonatate for Resident #3 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
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Licensee will contact the prescribing physician and obtain completed PRN Authorizations Letters for the PRN medications taken by all residents in care including Resident #2 and Resident #3. Submit evidence that PRN Authorization Letters are maintained in all the residents' files by 11/20/23
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:Kristin Heffernan
LICENSING EVALUATOR NAME:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2023


LIC809 (FAS) - (06/04)
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