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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850128
Report Date: 03/11/2024
Date Signed: 03/11/2024 07:29:39 PM

Document Has Been Signed on 03/11/2024 07:29 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:
03/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Rebeka Durgaryan, AdministratorTIME COMPLETED:
07:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool and was let into the home by Naira Aghajanyan, staff. Rebeka Durgaryan, Administrator was contacted by staff and she arrived at 10:44 *am to conduct the visit. The reason for today's visit was provided.

The home is a single storey family home consisting of 5 bedrooms, 3 full bathrooms, a living room, dining room, a den, office and a kitchen. The three back bedrooms are used by residents, the bedroom located by the front common bathroom is used for storage and the bedroom located by the front door is used as a staff room. The home has a fire place with the gas capped off and the fire grates dismantled. The facility is fire cleared for 1 BEDRIDDEN and 5 NON-AMBULATORY residents. Bedroom #2 is designated for Bedridden use.

On today's visit all 12 domains of the CARE Inspection Tool was reviewed, 6 resident and 6 staff files were reviewed and a tour of the entire facility, inside and outside was conducted and the following were observed:
  • the living room, dining room and kitchen all contained the required furnishings and appliances related to the designated use of the room.
  • sufficient perishable foods for a minimum of 2 days and non-perishable foods for a minimum of 7 days were observed.
  • Bedroom #1 located to the left back of the facility was observed with 2 hospital beds, 2 chairs, 2 small dressers with 2 lamps and a closet that was missing its doors. No night stands were provided
  • The back den was observed with a sofa and a stand. The back door was opened and the auditory device was not operational
  • Bedroom #2 was observed with 2 hospital beds, 1 tall dresser, 2 night stands, 1 lamp, 2 portable closets and 2 chairs. Overhead lighting was observed and provided sufficient lighting. The exit
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2024
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 03/11/2024 07:29 PM - It Cannot Be Edited


Created By: Christine Yee On 03/11/2024 at 05:38 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: 03/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(b)
Other Provisions
(b) At least one administrator, facility manager, or designated substitute who is at least 21 years of age and has qualifications adequate to be responsible and accountable for the management and administration of the facility pursuant to Title 22 of the California Code of Regulations shall be on the premises 24 hours per day. The designated substitute may be a direct care staff member who shall not be required to meet the educational, certification, or training requirements of an administrator. The designated substitute shall meet qualifications that include, but are not limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above per review of Staff #2 and Staff #3's files, there weren't any completed LIC308 designating the 2 staff as responsible staff during the day and night shift which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2024
Plan of Correction
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The Licensee will complete an LIC308 Designation of Facility Responsibility for Staff #2 and Staff #3 and for any staff who is responsible for management of the facility in the absence of the facility administrator by 3/18/24.
Type B
Section Cited
CCR
87705(j)
87705 Care of Persons with Dementia: (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above per tour of the facility, the auditory devices mounted on all three exit doors located in the front, the back door and in bedroom #2 were all tested and were not operational. The batteries were all depleted poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2024
Plan of Correction
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The Licensee will do monthly testing on all 3 exit doors to ensure that the batteries are not depleted, to ensure that the auditory devices are operational at all times. *****************batteries were replaced in the auditory devices during today's visit***************
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: 03/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2024


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Document Has Been Signed on 03/11/2024 07:29 PM - It Cannot Be Edited


Created By: Christine Yee On 03/11/2024 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: 03/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
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:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above per review of all Resident's files,consent forms were not completed, Identification and Emergency Forms(LIC9020) were not completed, a couple of Appraisal/Needs and services were not completed, missing Centrally Stored Medication Destruction Records, .which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2024
Plan of Correction
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Licensee will review all resident files to ensure that the resident files contain all the documents/information referenced in Section 87506(a) are in place by 3/18/24
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above per tour of the facility, Bedroom #1 and Bedroom #3 are missing closet doors which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2024
Plan of Correction
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Licensee will ensure that all facility closet doors are repaired and replaced when damaged. Licensee will replace the closet doors in bedroom #1 and bedroom #3 and submit evidence of correction by 3/18/24.
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: 03/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2024


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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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: NO HO RESIDENTIAL CARE, INC.
FACILITY NUMBER: 195850128
VISIT DATE: 03/11/2024
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  • door was opened and the auditory device mounted on the door was not operational
  • the common bathroom designated for resident use was observed with a shower stall, a sink, a toilet, grab bars, shower chair and a non-skid mat.
  • Located in the residents' bathroom is the washing machine and dryer.
  • Water was tested and the temperature read 119.6 degrees Fahrenheit
  • Bedroom #3 was observed with 2 hospital beds equipped with full bed rails that were lowered, 1 tall dresser, 1 lamp, 1 chair and a closet. Administrator was advised that the full rails are not permitted but was advised that they are not used and confirmed by Staff #2.
  • The fourth bedroom located by the dining room was observed used for storage of wheelchairs and a hospital bed. Administrator was advised that the hospital bed may not be used by any residents as this would put the facility in violation of their fire clearance and the recommendation was made to dismantle the bed or placed in storage elsewhere.
  • The common bathroom was observed with a shower stall, a toilet and a sink. The bathroom contained 2 shower chairs, grab bars, a non-skid mat. Water temperature was tested and read 117.6 degrees Fahrenheit.
  • The fifth bedroom is used for storage and a bed was also observed. Per the Administrator she and night staff use the room when working nights.
  • The office located behind the dining room has cabinets for storage and a computer.
  • The common bathroom located behind the dining room is equipped with a shower, a toilet and a sink and is designated solely for staff use.
  • The facility has liability insurance that meets Title 22 requirements
  • First Aid Kit and manual was observed and met Title 22 requirements.
  • Plenty linens were observed in the closets located by the dining room
  • The facility has 2 fire extinguishers, one located in the kitchen and one in the back den.
  • The smoke/carbon monoxide combination detectors were tested and were operational
  • The front yard was observed with tables and chairs and the back yard had chairs and a folded umbrella. Also located in the backyard was a storage shed.
  • A ramp was observed in the back leading out from bedroom #2.
  • Overall, the facility, inside and outside were observed to be clean and well maintained.
Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Any deficiencies not cited today will be addressed on a return visit.
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: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024
LIC809 (FAS) - (06/04)
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