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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850146
Report Date: 05/29/2024
Date Signed: 05/30/2024 08:36:09 PM

Document Has Been Signed on 05/30/2024 08:36 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:MY HOME OF AGINGFACILITY NUMBER:
195850146
ADMINISTRATOR/
DIRECTOR:		KYKHOSROWPOUR, VISHTASBFACILITY TYPE:
740
ADDRESS:23817 BESSEMER STREETTELEPHONE:
(818) 433-4592
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 6CENSUS: 6DATE:
05/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:00 PM
MET WITH:Vishtasb Kykhosrowpour and Farnaz ServatiTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Zabel Chochain arrived at the facility unannounced to conduct a required Annual visit. LPA met with Administrator and Farnaz Servati and explained the reason for the visit.
The LPA toured the physical plant areas inside and outside, with Administrator at 4pm., to ensure there are no health and safety hazards. BEDROOMS: There are (6) six bedrooms designated for resident use. Bedroom #1 has a direct exit to the exterior. The bedrooms are furnishing with clean linens, appropriate furnishings, and sufficient lighting for resident use. RESTROOMS: There are (4) four bathrooms designated for residents use. (2) two bathrooms are located inside the resident bedrooms and (2) two are located in the hallway. Bathrooms observed clean, sanitary, and in operating condition with grab bars and non-skid surfaces. Cleaning supplies observed in the restroom located in the hallway at approximately 4:35pm. Licensee/Administrator removed the four clean solution bottles and locked it in the garage during visit. KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be properly stored and locked at time of visit. COMMON SPACES: The common spaces included the living room; dining area and office area. The LPA observed cameras in all common spaces and exterior. All areas were clean, sanitary and in good repair. Smoke detectors are hardwired and interconnected, there is a Carbon Monoxide detector installed at the facility. The fire extinguisher was observed to be in compliance within one year. The LPA observed required postings in the entrance hallway. BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. There is a pool on the property that was observed to be gated and locked at the time of the visit. The LPA observed a Laundry room which is located inside the attached garage. Laundry detergents, cleaning supplies, pesticides, and/or toxins are also stored in the garage/laundry area.

Due to time constraints, the annual inspection will be completed on a follow-up visit. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Exit interview held. Copy of report and appeal rights provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE: DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/29/2024
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 05/30/2024 08:36 PM - It Cannot Be Edited


Created By: Zabel Chochian On 05/29/2024 at 05:14 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: MY HOME OF AGING
FACILITY NUMBER: 195850146

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(1)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (1) Postural supports shall be limited to appliances or devices such as braces, spring release trays, or soft ties, used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. R1 was observed in a wheelchair with a tray attached in front which was observed strapped where resident is unable to release self out of wheelchair. Licensee/Administrator and staff released the straps. This posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2024
Plan of Correction
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Licensee/Administrator unstrapped the tray from the wheelchair and acknowledged understanding that this type of action is not allow and is restricting movement. Licensee/Admiistrator and staff both acknowledged understanding and will not use any form of device that restricts movement of any resident. Corrected during visit.
Type B
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

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. LPA observed cleaing suppliesaccessible to resident in the restroom located in the hallway were resident bedrooms are located. This poses a potential health and safety risk to persons in care.
POC Due Date: 05/29/2024
Plan of Correction
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Licensee/Administrator removed the 4 cleaning solution bottles from the residents restroom and locked it in the garage during todays visit. Licensee/Administrator spoke with the staff during the visit and remind staff not to leave any cleaning solutions accessible to residents at anytime. Corrected during 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:Desaree Perera
LICENSING EVALUATOR NAME:Zabel Chochian
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024


LIC809 (FAS) - (06/04)
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