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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850128
Report Date: 02/20/2024
Date Signed: 02/20/2024 05:11:52 PM

Document Has Been Signed on 02/20/2024 05:11 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: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:
02/20/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:27 PM
MET WITH:Rebeka Durgaryan, AdministratorTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Yee conducted an unannounced case management visit due to the deficiencies noted on today's visit and met with Rebeka Durgaryan, Administrator. The reason for today's visit was explained.

LPA Yee reviewed all 6 residents files and observed that the residents files were incomplete:
  • Resident #1 - it is unknown if the doctor determined if resident is able to leave the facility without assistance. It is also unknown if the resident has any valuables to declare
  • Resident #2 - it is unknown if the resident is able to leave the facility unassisted, the Physician's report does not provide the resident's primary and secondary diagnosis
  • Resident #3 - it is unknown if the resident has any valuables
  • Resident #4 - it is unknown if the resident can leave the facility unassisted
  • Resident #5 - moved in on 12/28/23 and does not have a Physician's report with the results of a TB test, no medical consent forms, Resident Rights, no Preplacement Assessment, Appraisal Needs and Services, Resident Rights
  • Resident #6 does not have evidence of a TB test


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

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: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2024
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 02/20/2024 05:11 PM - It Cannot Be Edited


Created By: Christine Yee On 02/20/2024 at 04:31 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: 02/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/27/2024
Section Cited
CCR
87506(a)

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87506 Resident Records: 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.


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The Licensee will read Title 22, Section 87506 in its entirety to ensure that all resident files contain the required information noted in the section. Licensee will reivew all resident files for completeness and submit a signed written statement that the Section was read and all files were reviewed and
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This requirement was not met as evidenced by: Files for Resident #1 - Resident #6 were missing information noted on the LIC809 report and this is a potential risk to the personal rights and a health risk to the residents in care.
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contains all the required information by 2/27/24

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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: 02/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024


LIC809 (FAS) - (06/04)
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