Community Care Licensing

Document Has Been Signed on 09/15/2023 06:15 PM - It Cannot Be Edited

FACILITY NAME:	LOVE IS US		FACILITY NUMBER:	195850278
ADMINISTRATOR:	GHAZARYAN, ANI		FACILITY TYPE:	740
ADDRESS:	7063 TYRONE AVE		TELEPHONE:	(818) 397-3456
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY: 6		CENSUS: 5	DATE:	09/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Lydia Gonzalez, House Manager		TIME COMPLETED:	06:20 PM

SUPERVISORS NAME: Kristin Heffernan LICENSING EVALUATOR NAME: Christine Yee LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2023

Link to Parent Document Below:

FACILITY NAME: LOVE IS US	FACILITY NUMBER: 195850278
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/15/2023

Type A

Section Cited

HSC

1569.17(c)(1)(A)

(c)(1)(A) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in a facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation 9/15/23, the licensee did not comply with the section cited above per observation of an individual, Teresa Gomez, going in and out of the residents's room and was cleaning the residents rooms without supervision. The only staff was working in the kitchen or assisting residents. Per information obtained, the individual will be cleaning the facility 2 times a week, which poses an immediate health, safety or personal rights risk to persons in care as she has not obtained a criminal record clearance. She started today. Immediate civil penalties were assessed.
	POC Due Date: 09/16/2023
	Plan of Correction
1 2 3 4	The Licensee will provide a written and signed plan of action as to how she will ensure that all individuals, that are not residents, present at the facility obtain a criminal record prior to being present at the facility or are supervised at all times

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Kristin Heffernan LICENSING EVALUATOR NAME: Christine Yee LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2023

Link to Parent Document Below:

FACILITY NAME: LOVE IS US	FACILITY NUMBER: 195850278
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/15/2023

Type B

Section Cited

CCR

87411(f)

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as the health screening for Lydia Gonzalez was not completed by the physician and it is unknown if she is in good health to perform the staff duties at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/22/2023
	Plan of Correction
1 2 3 4	Licensee will contact the doctor to obtain a completed Physican's Report with the results and documentation of the physical and the results of the TB test for Lydia Gonzalez by POC date - 9/22/23 and maintain in her file. Fax a copy of the completed documentation to Licensing.

SUPERVISOR'S NAME: Kristin Heffernan LICENSING EVALUATOR NAME: Christine Yee LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2023

Link to Parent Document Below:

FACILITY NAME: LOVE IS US	FACILITY NUMBER: 195850278
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/15/2023

Type B

Section Cited

HSC

1569.618(a)

(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as there were no completed LIC308 designating Lydia Gonzalez' as responsible staff in her file. The Administrator was not present at the faciliy. There is also no completed LIC308 designating any responsible staff for the night shift which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/22/2023
	Plan of Correction
1 2 3 4	Licensee will complete an LIC308 to designate a responsible facility staff who is able to perform the duties of an administrator and is able to deal with emergency personnel when the Administrator is temporarily absent from the facility for for each shift by 9/22/23

Type B

Section Cited

CCR

87412(f)

(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above since the staff files, including the Administrator's were requested and it was not provided since the files are not maintained onsite or is stored in the Administrator's computer which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/22/2023
	Plan of Correction
1 2 3 4	Licensee will provide Licensing with a signed, written plan outlining how the facility will ensure that all files will be maintained on the premises and made readiliy available to Licensing by 9/22/23

SUPERVISOR'S NAME: Kristin Heffernan LICENSING EVALUATOR NAME: Christine Yee LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2023

FACILITY NAME: LOVE IS US	FACILITY NUMBER: 195850278
	VISIT DATE: 09/15/2023

Link to Parent Document Below:

FACILITY NAME: LOVE IS US	FACILITY NUMBER: 195850278
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/15/2023

Type A

Section Cited

CCR

87468.1(a)

Personal Rights of Residents in All Facilities : (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: 6)To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as the front door was installled with a security latch that prevents residents from exiiting from the front door. It was also installed real high on the door that it was not reachable by vertically challenged resident in an emergency which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/16/2023
	Plan of Correction
1 2 3 4	The Licensee was asked to remove the security latch and the latch was removed at the time of the visit.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Kristin Heffernan LICENSING EVALUATOR NAME: Christine Yee LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2023

Link to Parent Document Below:

FACILITY NAME: LOVE IS US	FACILITY NUMBER: 195850278
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/15/2023

Type B

Section Cited

CCR

87412(a)

Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above since the Administrator created a file for herself and her spouse poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/22/2023
	Plan of Correction
1 2 3 4	The Licensee will review Title 22, Section 87412 and create files for the Administrator, Spouse and all stall and volunteers and review current staff files to ensure that it contains all the required items by 9/22/23

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Kristin Heffernan LICENSING EVALUATOR NAME: Christine Yee LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2023