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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850128
Report Date: 05/21/2021
Date Signed: 05/21/2021 05:28:36 PM

Document Has Been Signed on 05/21/2021 05:28 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:NO HO RESIDENTIAL CARE, INC.FACILITY NUMBER:
195850128
ADMINISTRATOR:DURGARYAN, REBEKAFACILITY TYPE:
740
ADDRESS:6605 AGNES AVENUETELEPHONE:
(818) 404-0290
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 6CENSUS: 6DATE:
05/21/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Rebekah DurgaryanTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) KaSandra Lopez and Salia Walker conducted an unannounced Case Management - Deficiencies inspection. When the LPAs arrived there were six residents and one staff present. Administrator Rebeka Durgaryan arrived at approximately 10:12 AM.

During the investigation for complaint control #29-AS-20210517145549, the LPAs observed the following deficiencies.

At 9:45 AM, the LPAs observed the gate entrance to the facility to be locked from both sides, needing a key to unlock the door from inside or outside the facility.

At 11:11 AM, the administrator advised they did not have a facility file for Resident #1 (R1) and only had their discharge paperwork from their previous placement.

Exit interview conducted. A copy of the report will be emailed to the administrator by the end of the day.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2021
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 2
Document Has Been Signed on 05/21/2021 05:28 PM - It Cannot Be Edited


Created By: Kasandra Lopez On 05/21/2021 at 02:57 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: NO HO RESIDENTIAL CARE, INC.
FACILITY NUMBER: 195850128

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/21/2021
Section Cited
CCR
87203

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87203 Fire Safety
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 evidence by:
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The administrator removed the lock during the inspection. Plan of correction cleared.

This is an immediate health and safety risk and a civil penalty is being assessed.
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Based on observation, the licensee did not comply with the section cited above as the entrance gate was locked from the inside of the property to the facility grounds which poses an immediate safety risk to residents in care.
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Type B
06/04/2021
Section Cited
CCR87506(a)

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87506(a) Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information.
This requirement is not met as evidenced by
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The administrator shall submit proof R1 has a facility file with required records and documentation by 06/04/2021.
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Based on observation, the licensee did not comply with the section cited above as one resident (R1) out of six residents does not have a facility file which poses potential health and safety risk to residents in care.
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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:Desaree Perera
LICENSING EVALUATOR NAME:Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2021


LIC809 (FAS) - (06/04)
Page: 2 of 2