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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850179
Report Date: 07/21/2023
Date Signed: 07/21/2023 05:30:16 PM

Document Has Been Signed on 07/21/2023 05:30 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:YMZ ASSISTED LIVINGFACILITY NUMBER:
195850179
ADMINISTRATOR:DURGARYAN, REBEKAFACILITY TYPE:
740
ADDRESS:6206 KLUMP AVENUETELEPHONE:
(818) 358-2955
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 6CENSUS: 5DATE:
07/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Rebeka Durgaryan, AdministratorTIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst(LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool. LPA Yee was let into the home by Sydykova Bishkek, Staff. Staff contacted the Administrator via telephone and she arrived at 10:15am to conduct the visit. The reason for today's visit was provided.

The facility is a single storey home consisting of a living room, dining room, kitchen, 3 bedrooms and 2 full bathrooms. Located on the property in a separate 2 storey building that is in the process of being remodeled and a fenced in swimming pool. The facility has a fire clearance for 5 NON-AMBULATORY and 1 BEDRIDDEN residents.

The following was observed on today's visit:
  • The living room, dining room and kitchen had the appropriate furnishings.
  • Insufficient perishable foods and sufficient non-perishable foods were observed
  • The three resident bedrooms were all observed with the required furnishing except for the following: Bedroom located to the right of the common bathroom needs a chair and dressers and the window needs new blinds for resident privacy. The bedroom located to the left of the common bathroom needs dresses.
  • Located in the bedroom to the left of the common bathroom is a full private bathroom. Grab bars and non-skid mats were observed. The water temperature was tested and read 152.5 degrees Fahrenheit.
  • The common bathroom was observed with grab bars and a non-skid mat. The water temperature was tested and it read 147.6 degrees Fahrenheit.
  • The interconnected smoke detectors were tested and they were operational. The smoke detector located directly in front of the kitchen door was not installed and was observed with hanging wires.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 07/21/2023 05:30 PM - It Cannot Be Edited


Created By: Christine Yee On 07/21/2023 at 03:32 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: YMZ ASSISTED LIVING
FACILITY NUMBER: 195850179

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(7)
Personal Accommodations and Services
(7) Fireplaces and open-faced heaters shall be adequately screened.

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 in 1 out of 1 count which poses/posed a potential health, safety or personal rights risk to persons in care. which poses/posed a potential health, safety or personal rights risk to persons in care. The fire place located in the living room is covered by a glass screen but is not made inaccessible to the residents in care, Per Administrator, they don't use the fireplace.
POC Due Date: 07/28/2023
Plan of Correction
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LIcensee will take steps to make the fire place inaccessible to the residents in care. A screen placed in front of the fire place will meet the intent. Provide evidence that the deficiency has been corrected by 7/28/23
Type B
Section Cited
CCR
87303(a)
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 in 1 out of 13 rooms inspected, the blinds in the bedroom located to the right of the common bathroom are broken and do not provide privacy to the residents assigned to the room, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/28/2023
Plan of Correction
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Licensee will replace the blinda and provide a copy of the receipt or self certify that the blinds have been replaced by 7/28/23.
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: 07/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023


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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: YMZ ASSISTED LIVING
FACILITY NUMBER: 195850179
VISIT DATE: 07/21/2023
NARRATIVE
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  • The smoke detector located directly in front of the left bedroom is a combination smoke detector and carbon monoxide detector. The carbon monoxide feature was operational when the smoke detectors were tested.
  • The only fire extinguisher is located in the bedroom located by the living room.
  • The facility uses cameras in the common areas - 1-living room, 1- kitchen and 2-in front of the home on both corners of the home. Licensee will send an addendum to their Plan of Operations to indicate cameras are in use, the purpose of the cameras and who has access to the information and send to Licensing.
  • The backyard has a covered patio furnished with a coffee table and 2 sofas, swimming pool and a separate structure. The whole property is fenced in.



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

Exit interview was conducted with Peter Atoyan due to the Administrator having an afternoon appointment.
APPEALS RIGHTS were discussed and a copy was provided.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
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Page: 3 of 7
Document Has Been Signed on 07/21/2023 05:30 PM - It Cannot Be Edited


Created By: Christine Yee On 07/21/2023 at 04:18 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: YMZ ASSISTED LIVING
FACILITY NUMBER: 195850179

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(3)(E)
Personal Accommodations and Services: (c) E) Portable or permanent closets and drawer space in the bedrooms for clothing and personal belongings. A minimum of eight (8) cubic feet (.743 cubic meters) of drawer space per resident shall be provided.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation in 2 out of 3 rooms inspected, the 2 bedrooms located in the back by the common bathroom did not contain the appropriate number of dressers for the 4 residents' use, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/28/2023
Plan of Correction
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The Licensee will purchase/provide the required dressers to the residents located in the 2 back bedrooms by the common bathroom by 7/28/23. Provide evidence that the deficienciy has been corrected.
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 in 1 out of 6 count of smoke detectors tested, the smoke detector in front of the kiitchen was observed to be dismantled and the wires were left hanging, poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/28/2023
Plan of Correction
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The Licensee will replace the smoke detector and provide evidence that the smoke detector has been replaced by providing a copy of the receipt or self certify by 7/28/23
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: 07/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023


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Document Has Been Signed on 07/21/2023 05:30 PM - It Cannot Be Edited


Created By: Christine Yee On 07/21/2023 at 04:49 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: YMZ ASSISTED LIVING
FACILITY NUMBER: 195850179

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
87303 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 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 in 1 out 2 tests conducted for the water temperature taken in the private bathroom read 152.5 degrees Fahrenheit and the water temperature in the common bathroom read 147.6 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2023
Plan of Correction
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The Licensee will immediately adjust the water heater thermostat to reduce the water temperature to Title 22 requirements ranging between 105 degrees to 120 degrees Fahrenheit. Provide evidence that the deficiency has been corrected by 7/22/23.
Type A
Section Cited
CCR
87468.1(a)(3)
87468.1 Personal Rights of Residents in All Facilities
(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.

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 as food pantry and cabinets located in the kitchen, containing foods were observed locked with a padlock and child locks,] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2023
Plan of Correction
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Licensee will remove the locks off the food pantry and kitchen cabinets to allow the residents access to food. Provide evidence that the padlocks were removed by 7/22/23
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: 07/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023


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Document Has Been Signed on 07/21/2023 05:30 PM - It Cannot Be Edited


Created By: Christine Yee On 07/21/2023 at 05:07 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: YMZ ASSISTED LIVING
FACILITY NUMBER: 195850179

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply
(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises


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, insufficient perishables such as vegetables and fruits were observed in the refrigerator. Per staff, Administrator is purchasing more food today - 7/21/23 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2023
Plan of Correction
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Licensee will provide a copy of the receipt for the food purchased by 7/22/23
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: 07/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023


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Document Has Been Signed on 07/21/2023 05:30 PM - It Cannot Be Edited


Created By: Christine Yee On 07/21/2023 at 05:15 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: YMZ ASSISTED LIVING
FACILITY NUMBER: 195850179

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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. the back yard and front yard needs general cleaning, unused washing maching, dryer, bedrails, fence needs to be stored away, cardboard boxes discarded, and the wire hanging directly in front of the sliding glass door of the back room is addressed, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/28/2023
Plan of Correction
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Licensee will conduct generall cleaning, store all unused items noted above and sweep up all the dried leaves. Provide evidence of correction by 7/28/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: 07/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023


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