Community Care Licensing

Document Has Been Signed on 08/28/2024 06:04 PM - It Cannot Be Edited

FACILITY NAME:	YMZ ASSISTED LIVING		FACILITY NUMBER:	195850179
ADMINISTRATOR/ DIRECTOR:	DURGARYAN, REBEKA		FACILITY TYPE:	740
ADDRESS:	6206 KLUMP AVENUE		TELEPHONE:	(818) 358-2955
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY: 6		CENSUS: 6	DATE:	08/28/2024
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:43 PM
MET WITH:	Rebeka Durgaryan, Administrator		TIME VISIT/ INSPECTION COMPLETED:	06:10 PM

SUPERVISORS NAME: Kristin Heffernan LICENSING EVALUATOR NAME: Christine Yee LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024

Link to Parent Document Below:

FACILITY NAME: YMZ ASSISTED LIVING	FACILITY NUMBER: 195850179
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/28/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/04/2024 Section Cited CCR 87632(d)(2)	1 2 3 4 5 6 7	Hospice Care Waiver: If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver as necessary to ensure the well-being of terminally ill residents and of all other facility residents, which shall include, but not be limited to, the following requirements.	1 2 3 4 5 6 7	Licensee will read Title 22 Section 87632 and 87633 and submit a written statement that the sections were read and understood and that the Licensee will comply with all requirements noted in the Section. Licensee will also submit written hospice notification letters containing all
	8 9 10 11 12 13 14	The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services...... R1, R4 & R5 are on hospice and was not reported	8 9 10 11 12 13 14	the required information noted in the Section being cited to the Department by 9/4/24.
Type B 08/30/2024 Section Cited CCR87211(a)(1)(A)	1 2 3 4 5 6 7	Reporting Requirements: (a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within 7 days	1 2 3 4 5 6 7	The Licensee will ensure that all resident deaths, whether it occurred in the faciity or away from the facility in a hospital is reported to the Depatment. Licensee will complete an LIC624A for the death of Resident #1 and submit to the Department by no later than 8/30/24
	8 9 10 11 12 13 14	of the occurrence of any of the events specified in (A) through (D) below. A) Death of any resident from any cause regardless of where the death occurred, including..... a hospital, en route to or from a hospital, or visiting away from the facility. Resident #1's death was not reported to the Department	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Kristin Heffernan LICENSING EVALUATOR NAME: Christine Yee LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024

Link to Parent Document Below:

FACILITY NAME: YMZ ASSISTED LIVING	FACILITY NUMBER: 195850179
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/28/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/30/2024 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	Reporting Requirements: (a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within 7 days	1 2 3 4 5 6 7	Licensee will ensure that all incidents which threatens the welfare, safety or health of any resident, including hospitalizations are reported to the Department. Licensee will complete an LIC624 to report the hospitalization of R1 by 8/30/24.
	8 9 10 11 12 13 14	of the occurrence of any of the events specified in (A) through (D) below. Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. R1's hospitalization wasn't reported	8 9 10 11 12 13 14
Type B 08/29/2024 Section Cited CCR87608(a)(5)(B)	1 2 3 4 5 6 7	Postural Support: Based on the individual's preadmission appraisal, and subsequent changes to that appraisal.... Postural supports may be used under the following conditions.Under no circumstances shall postural supports include tying, depriving, or limiting the use .	1 2 3 4 5 6 7	Licensee will immediately remove the full bed rail and submit evidence that the full bed rails have been removed by 8/29/24.
	8 9 10 11 12 13 14	of a resident's hands or feet.Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. R7's hospital bed was observed equipped with a full bed rail. (not on hospice)	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Kristin Heffernan LICENSING EVALUATOR NAME: Christine Yee LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024