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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850128
Report Date: 02/24/2023
Date Signed: 02/24/2023 01:30:59 PM

Document Has Been Signed on 02/24/2023 01:30 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 NORTH, 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:
02/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Rebeka Durgaryan, AdministratorTIME COMPLETED:
01:45 PM
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Licensing Program Analyst(LPA) Christine Yee conducted an unannounced required annual inspection, with emphasis on the infection control procedures and practices and was let into the home by Naira Aghajanyan, Staff. LPA Yee's temperature was taken upon entry. Rebeka Durgaryan, Administrator was contacted via telephone and she arrived at 9:36am to conduct the visit. The reason for today's visit was explained.

The home is a single storey home consisting of 5 bedrooms, 3 full bathrooms, a living room, dining room, office and a kitchen. The home has a fire place and is not used. Gas is capped off and fire grates dismantled.

During this inspection, a tour of the home, inside and outside was conducted beginning at 11:00am and the following was observed:
  • Coronavirus poster on front door with safety advices and tips
  • Coronavirus poster on wall by the front door
  • Plenty of Personal Protective Equipment were stored in 3 outside storage cabinets
  • Hand sanitizers were observed around the home
  • Facility has cameras located in the dining room, living room and 4 cameras located outside. Licensee is the only one who has access to the recorded information

Continued on LIC809-C
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2023
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 02/24/2023 01:30 PM - It Cannot Be Edited


Created By: Christine Yee On 02/24/2023 at 11:53 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: 02/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)
Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement was not met as evidenced by


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on test of the water, the licensee did not comply with the section cited above in 2 out of 2 tests which poses an immediate health, safety or personal rights risk to persons in care. Water temperature tested 140.6 degrees in the front bathroom and 137.4 degrees in the back bathroom
POC Due Date: 02/25/2023
Plan of Correction
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The Licensee will adjust the thermostat to bring the temperature to the required Title 22 requirements of 105 degrees to 120 degrees Fahrenheit by 2/25/23 and if not doable sumbit a plan as to how the licensee will ensure the safety of the residents until a contractor can correct the problem by 2/25/23
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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023


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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: NO HO RESIDENTIAL CARE, INC.
FACILITY NUMBER: 195850128
VISIT DATE: 02/24/2023
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  • Staff were observed wearing surgical mask
  • There were sufficient perishable and non-perishable foods
  • Medications were centrally stored in 2 locked filing cabinets
  • Sharp knives were stored in a locked case in kitchen drawer
  • First aid kit was reviewed and met Title 22 requirements.
  • First aid manual was observed
  • Per tour of the 3 resident rooms, a hospital bed, lamps, night stands, chairs and closets were observed except, bedroom #3 is missing a dresser.
  • The front bedroom is used by staff
  • Per tour of the 2 full bathrooms-back and front- utilized by residents, non-skid mats were observed. The front bathroom was missing grab bars.
  • The interconnected Smoke and carbon monoxide combo detectors were tested and were operational.
  • The facility has 2 fire extinguishers - kitchen and in the back lounge were fully charged and expires on May 5, 2023
  • Water was tested in the front and back bathroom and the water temperature read 140.6 and 137.4 degrees, respectively
  • The backyard was observed to be clean and the front yard was set up with rattan chairs, a table with an umbrella for shade.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

Exit interview was conducted, Appeals Rights discussed and a copy of the report was provided.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/24/2023 01:30 PM - It Cannot Be Edited


Created By: Christine Yee On 02/24/2023 at 12:56 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: 02/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(4)
Maintenance and Operations:
(4) Grab bars shall be maintained for each toilet; bathtub and shower used by residents.

This requirement is not met as evidenced by:
The front bathroom was observed without a grab bar
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 count out of 1 count which posesa potential health, safety risk to the residents in care
POC Due Date: 03/03/2023
Plan of Correction
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The Licensee will take action to ensure that a grab bar is placed in the front bathroom and any bathroom that does not have a grab bar by 3/3/23. Provide evidence to licensing that the correction has been made.
Type B
Section Cited
CCR
87307(3)(B)
Personal Accommodations and Services: 3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers.
This requirement is not met as evidenced by: Bedroom #3 was observed with 2 night stands and does not have a regulation sized dresser.
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in 1 out of 6 which poses a potential personal rights risk to persons in care.
POC Due Date: 03/03/2023
Plan of Correction
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Licensee will provide the resident in Bedroom #3 with a regulation sized dresser and provide Licensing with evidence that the dresser was provided
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:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023


LIC809 (FAS) - (06/04)
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