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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850128
Report Date: 09/14/2021
Date Signed: 09/14/2021 10:47:13 AM

Document Has Been Signed on 09/14/2021 10:47 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, 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: 5DATE:
09/14/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:24 AM
MET WITH:Rebeka Durgaryan, AdministratorTIME COMPLETED:
10:50 AM
NARRATIVE
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Licensing Program Analyst (LPA) Salia Walker conducted an unannounced Case Management-Deficiencies inspection visit at the facility today due to deficiencies observed during the subsequent visit of complaint control # 29-AS- 20210628101044.

At 08:39 a.m., the LPA identified there were two (2) staff to 5 residents. The staff #1 (S1) claimed that they have been working at the facility for ‘one month’. The LPA confirmed that this individual was not associated to this facility. At 9:00 a.m., it was revealed through interview with Administrator and identification verification that staff #2 (S2) was also not associated to this facility.



Pursuant to Title 22 of the California Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit interview conducted, today's reports and appeal rights were reviewed and issued.

Civil penalties issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2021
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 09/14/2021 10:47 AM - It Cannot Be Edited


Created By: Salia Walker On 09/14/2021 at 10:07 AM
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: 09/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/14/2021
Section Cited
CCR
87355(e)(2)

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87355(e)(2) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... in a licensed facility: (2) Request a transfer of a criminal record clearance…
This requirement is not met as evidenced by:
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The Administrator has agreed to do the following:
1. Submit documentation for S1, and S2 to be associated with the facility with background clearance by 09/17/21.
Zero tolerance violation; immediate civil penalty assessed of $1000
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Based on interviews and observations, the licensee did not comply with the section cited above, as two individuals (S1, S2) have been working at the facility without a background clearance, which poses an immediate 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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Salia Walker
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2021


LIC809 (FAS) - (06/04)
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