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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850128
Report Date: 12/28/2021
Date Signed: 12/28/2021 06:39:04 PM

Document Has Been Signed on 12/28/2021 06:39 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:
12/28/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:11 PM
MET WITH:Rebeka Durgaryan, AdministratorTIME COMPLETED:
06:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Salia Walker and Elsie Campos 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-20211129153412.

At 2:11 p.m., the LPAs observed a key inserted on the facility’s front entrance doorknob on the outside. At 2:13 p.m., the LPAs advised staff #1 (S1) the facility entrance key is not to be on the front doorknob for the safety of the residents and staff. S1 immediately removed the facility entrance and acknowledged understanding. At 2:49 p.m., the LPAs advised Administrator Rebeka Durgaryan of the facility key being inserted in the front entrance doorknob. The Administrator acknowledged, and explained the reason for the key being placed on the doorknob is per resident request. The LPAs explained to the Administrator and residents the severity of leaving the facility key on the outside front entrance doorknob, as any one can enter the facility, which poses immediate risk to the residents in care.

At 2:13 p.m., Resident #1 (R1) opened the front door providing access for the LPAs to enter. At 2:13 p.m., S1 rushed to the LPAs stating that S1 was in the middle of changing another resident. During the physical plant tour at 2:15 p.m., the LPAs also observed a mop bucket with water in the common bathroom. S1 stated she was also in the middle of mopping the common bathroom floor, but stepped away to tend to other resident needs. At 2:49 p.m., the Administrator confirmed R1 has Dementia. The LPAs advised the Administrator that upon arrival R1 opened the door for the LPAs as S1 was unable to open the door timely due to being occupied assisting another resident. The administrator acknowledged understanding. Civil Penalties are being assessed today for a Repeat Violation on section 87411(a), as the facility had been cited for the same citation section 87411(a) on 09/14/2021.


Continue on LIC809C..
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2021
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 7
Document Has Been Signed on 12/28/2021 06:39 PM - It Cannot Be Edited


Created By: Salia Walker On 12/28/2021 at 06:05 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: 12/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/31/2021
Section Cited
CCR
87705(f)(2)

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87705(f)(2) Care of Persons with Dementia. The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as... cleaning supplies ...
This requirement is not met as evidenced by:
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Staff locked and secured items during visit.
The Licensee has agreed to do the following:
1. Submit staff training log of section 87705(f)(2) to CCL by 12/31/2021.
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Based on LPAs observation, the licensee did not comply with the section cited above, as ointments, and multiple medications were accessible to residents with dementia, which poses an immediate 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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Salia Walker
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2021


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Document Has Been Signed on 12/28/2021 06:39 PM - It Cannot Be Edited


Created By: Salia Walker On 12/28/2021 at 05:53 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: 12/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/31/2021
Section Cited
CCR
87555(b)(8)

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87555(b)(8) General Food Service Requirements(b)The following food service requirements shall apply:(8)All food shall be of good quality.. Food in damaged containers shall not be accepted, used or retained.
This requirement is not met as evidenced by:
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The Licensee agreed to do the following:
1. Audit all food, and submit proof of completion to CCLD by 12/31/2021.
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Based on observation, the licensee did not comply with the section cited above, as expired food was observed in one (1) out of two (2) facility kitchen refrigerators, which poses a potential health, and safety risk to persons 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: 12/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/28/2021 06:39 PM - It Cannot Be Edited


Created By: Salia Walker On 12/28/2021 at 05:56 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: 12/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/29/2021
Section Cited
CCR
87411(a)

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87411(a) Personnel Requirements – General: Facility personnel shall at all times be.. competent to provide the services necessary to meet resident needs.. facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by:
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The Licensee has agreed to do the following:
1. Submit proof of staff retraining on section 87411(a) to CCLD by 12/29/2021.
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Based on LPAs observations, the Licensee did not comply with the section cited above, as the Licensee failed to ensure Facility personnel is competent to provide the services necessary to meet resident needs, as the front door had the facility key in the doorknob and a resident had to open the door for the LPAs due to staff being occupied with another resident, which poses a potential health and safety risk to residents in care.
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Type A
12/29/2021
Section Cited
CCR87705(f)(1)

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87705(f)(1) Care of Persons with Dementia: (f)The following shall be stored inaccessible to residents with dementia: (1)Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement is not met as evidenced by:
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S1 secured the culinary knives and sharp items upon observation. Plan of correction met.
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Based on LPAs observation, the licensee did not comply with the section cited, as culinary knives and additional sharp items were accessible during physical plant tour to residents with Dementia, which poses an immediate 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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Salia Walker
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2021


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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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: NO HO RESIDENTIAL CARE, INC.
FACILITY NUMBER: 195850128
VISIT DATE: 12/28/2021
NARRATIVE
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At 2:26 p.m., the LPAs observed two (2) cabinet doors unlocked containing accessible medications such as over the counter ointments ‘Calmoseptine’, and ‘Triple Antibiotic Ointment.’ At 2:30 p.m., the LPAs observed accessible medication in two (2) out two (2) facility refrigerators that were not properly stored inside a medication lock box. Medications accessible included; ‘risperidone,’ ‘Dulcolax,’ ‘Lorazepam,’ and ‘Sodium Chloride Inhalation Solution.’ The LPAs advised S1 and the Administrator all medications shall be stored inaccessible to residents with Dementia. The administrator stated the facility only has one medication lock box, but would immediately obtain a second medication lock box to secure the remaining resident medications that did not fit in the first lock box.
At 2:27 p.m., the LPAs observed the facility’s sharp items lock box was unlocked and accessible to residents in care. The LPAs advised S1 that knives, and sharps shall be locked and secured at all time inaccessible to residents in care. At 2:49 p.m., the LPAs advised the Administrator that the LPAs observed culinary knives, and other sharps were accessible in the kitchen, which poses an immediate health and safety risk to residents in care. The LPA advised the Administrator that all sharps including knives must remain locked and secured at all times while caring for persons with dementia. The Administrator acknowledged understanding.
At 2:31 p.m., During the physical plant tour the LPAs observed one (1) out of two (2) facility kitchen refrigerators contained expired condiments. S1 removed the expired condiments and discarded them into the trash bin.
At 3:04 p.m., the LPAs conducted a record review. Record review revealed, Resident #1 (R1) did not have a completed facility file, including a completed medical assessment, emergency identification, signed personal rights, resident appraisal, Appraisal needs and Services plan, centrally stored medication and destruction record, Consent to Medical Examination. The only records R1 had in file was hospital records. Record review also revealed the following, Resident #2 (R2) did not have a completed facility file, including a medical assessment, emergency identification, signed personal rights, resident appraisal, Appraisal needs and Services plan, centrally stored medication and destruction record. Record review revealed that Resident #3 (R3) did not have a completed facility file, including an admissions agreement, a completed medical assessment, emergency identification, signed personal rights, resident appraisal, Appraisal needs and Services plan, centrally stored medication and destruction record, Consent to Medical Examination. At 2:49 p.m., the LPAs advised the Administrator that all resident file shall be completed and contain the required forms filled out completely. The Administrator stated that she mailed the form for the residents to the responsible parties, but the responsible parties did not return the completed forms.
Continue on LIC809C..
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021
LIC809 (FAS) - (06/04)
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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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: NO HO RESIDENTIAL CARE, INC.
FACILITY NUMBER: 195850128
VISIT DATE: 12/28/2021
NARRATIVE
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At 3:20 p.m., during the record review the LPAs inquired about the Hospice Care Plans for R2, and R3. The Administrator stated that the ‘ABC Hospice’ did not provide the Care plan for R2. The Administrator also stated that ‘ABC Hospice’ retrieved the Hospice Care plan for R3. The LPAs advised the Administrator the required documentation for two (2) out of five (5) resident files did not contain the Hospice care plan. The LPAs advised the administrator that all records shall be maintained in the facility for the duration of three years.


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: 12/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 12/28/2021 06:39 PM - It Cannot Be Edited


Created By: Salia Walker On 12/28/2021 at 05:45 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: 12/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/31/2021
Section Cited
CCR
87633(b)

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87633(b) Hospice Care of 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:
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The administrator provided a copy of R3's Hospice Care plabn during the visit.
The Licensee agreed to do the following:
1. Submit required Hospice records for R2 to CCLD by 12/31/2021.
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Based on record review, the licensee did not comply with the section cited above, as two (2) out of five (5) resident files did not contain the resident Hospice care plan, which poses a potential health, and safety risk to persons in care.
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Type B
12/31/2021
Section Cited
CCR87507(a)(g)(A)

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87507 Admission Agreements (a) The licensee shall complete an individual written admission agreement,...(g) Admission agreements shall specify the following:(A) Rate for all basic services which the facility is required to provide in order to obtain and maintain a license.
This requirement is not met as evidenced by:
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The Licensee agreed to the following:
1. Submit proof R1, R2, and R3 completed and signed forms identified in the report to CCLD by 12/31/2021.
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Based on record review, the licensee failed to comply with the section cited above, as three (3) out of five (5) residents files were incomplete, which poses a potential personal rights 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: 12/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2021


LIC809 (FAS) - (06/04)
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