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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850166
Report Date: 07/07/2023
Date Signed: 07/07/2023 01:18:17 PM

Document Has Been Signed on 07/07/2023 01:18 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:AAA QUALITY RESIDENTIAL CARE FACILITYFACILITY NUMBER:
195850166
ADMINISTRATOR:KIRAKOSYAN, ELENFACILITY TYPE:
740
ADDRESS:7843 STANSBURY AVE.TELEPHONE:
(323) 485-4851
CITY:PANORAMA CITYSTATE: CAZIP CODE:
91402
CAPACITY: 6CENSUS: 4DATE:
07/07/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ovsanna Khayalyan, LicenseeTIME COMPLETED:
01:30 PM
NARRATIVE
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 Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Annual Continuation at the facility today continuing the inspection that began on 06/20/2023. At 11:38 a.m., the Licensee arrived at the facility.

At 11:10 a.m., the LPA toured the physical plant areas inside and outside, with Staff to ensure there are no health and safety hazards.

RECORD REVIEW: At 11:40 a.m., the LPA reviewed resident records for the two (2) new residents. All files were in order.

Between 11:47 a.m. and 12:30 p.m., LPA Peraldi conducted a review of medication and medication documentation with the Licensee for four (4) residents and observed the following: R1’s Aspirin 81 MG had 9 tablets remaining, however the medication was started on 06/16/2023 and the quantity was 15.

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8 and California Health and Safety Code the following deficiencies were cited (refer to LIC 809-D)

Exit interview conducted. A copy of the report of provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2023
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 07/07/2023 01:18 PM - It Cannot Be Edited


Created By: Emily Peraldi On 07/07/2023 at 12:59 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: AAA QUALITY RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 195850166

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as 1 of 4 resident medications reviewed contained inconsistencies with their medication amounts remaining and amounts documented as administered on the centrally stored which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/14/2023
Plan of Correction
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Administrator agreed to do a complete medication audit for the facility and training for all medication staff and submit documentation to CCL by POC due date.
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:Kristin Heffernan
LICENSING EVALUATOR NAME:Emily Peraldi
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023


LIC809 (FAS) - (06/04)
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