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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850306
Report Date: 09/17/2024
Date Signed: 09/17/2024 02:48:16 PM

Document Has Been Signed on 09/17/2024 02:48 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:AAA JERUSALEM STARSFACILITY NUMBER:
195850306
ADMINISTRATOR/
DIRECTOR:		SOHEILA NOROOZIFACILITY TYPE:
740
ADDRESS:5945 CAPISTRANO AVETELEPHONE:
(818) 888-1706
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 6CENSUS: 6DATE:
09/17/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Kristina AdamyanTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Angela Barutyan conducted an unannounced case management - incident visit at 10:20AM. The purpose of this visit is to conduct an investigation regarding a self-reported incident that occurred on 09/10/2024. Upon arrival, the LPA met with staff. Administrator Kristina Adamyan arrived at 10:35AM and the reason for the visit was explained. Entrance interview conducted.

On 09/11/2024, the Department received an incident report stating that on the early hours of 09/10/2024, Resident 1 (R1) left the facility unassisted, and staff were unaware. Resident 2 (R2) was woken up by the light coming from R1’s room and when R2 went to investigate, R2 found that R1 was not in their room. R2 notified Staff 1 (S1) around 12:30AM who went to investigate and found that the main entrance door was open. S1 looked inside and outside the facility and was unable to find R1. S1 notified Administrator Adamyan who arrived at the facility around 12:45AM and looked all throughout the facility and neighborhood. Around 2AM, Administrator Adamyan contacted nearby hospitals and the LAPD who arrived at the facility. During this time, Administrator Adamyan contacted R1’s family who arrived at the facility to continue the search. According to the report, R1 was found around 03:45AM and paramedics were promptly called to assess R1’s vitals. R1 was found to be dehydrated and was transferred to the hospital to receive fluids. R1 was discharged from the hospital around 11AM to the facility.

During today’s visit, LPA Barutyan conducted a brief physical plant tour at 10:22AM to ensure there are no health and safety hazards, conducted interviews with the Administrator, two (2) staff members, one (1) resident, and one (1) family member between 10:35AM-12:00PM, and conducted a file review. LPA requested and obtained copies of pertinent documents relevant to the investigation via email on 09/11/2024.

Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: AAA JERUSALEM STARS
FACILITY NUMBER: 195850306
VISIT DATE: 09/17/2024
NARRATIVE
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Record review of R1’s physician’s report dated 03/01/2023 indicates that R1 has dementia and is unable to leave the facility unassisted. R1 does not have an updated physician’s report for the current year. Record review of R1's appraisal of needs and services dated 03/15/2022 revealed that R1 requires assistance and guidance in their care plan. R1 does not have an updated reappraisal of needs and services. Interviews conducted with staff revealed that R1 is not able to ambulate and staff believe R1 was unlikely to have left the facility without some kind of assistance. LPA was informed that S1 found R1 three (3) hours after the search began in the backseat of R2’s vehicle. Staff stated that S1 did not hear the resident leave because R2 turned off the exit alarm and S1 was in the garage doing laundry.

Interview conducted with the Administrator revealed that S1 put residents to bed at 09:30PM. R1 woke up at 11:15PM and was hungry. R2 was also awake and together they went to the kitchen and asked S1 for food. After eating, S1 put R1 to bed and within forty (40) minutes at 12:30AM, R2 notified S1 that R1 was missing and left the facility. S1 found that the front door was open and began the search while also contacting the Administrator. Administrator stated that R2 has a tendency to turn off the exit alarm and S1 does rounds every two (2) hours to check on the residents, which is why R1 was able to leave without notice because S1 had just done a round forty (40) minutes prior. Administrator contacted the family, the LAPD, and nearby hospitals around 2AM. Administrator stated that R1 was eventually found by S1 at 03:30AM in the backseat of R2’s car of which the door was left ajar. According to staff and Administrator, R1 was missing from 12:30AM-03:30AM. Administrator stated that R1 was unlikely to have left on their own because R1’s cane was left behind in their room and R1 is unable to ambulate more than ten (10) feet without it. The driveway was also poorly lit and R1 needs assistance to sit down. Administrator stated it is unclear how R1 could have sat in the car on their own.

During the visit, LPA interviewed R1 who was confused and unable to recall any incidents besides going to the hospital last week for an unknown reason.

Furthermore, during an interview with R1’s family member, family member stated that the Administrator contacted them at 03:30AM, three (3) hours after R1 was found to be missing. Family arrived at 4AM and R1 was found at 04:30AM, meaning that R1 was missing for a total of four (4) hours. The interview also revealed that family was informed S1 was asleep when R2 notified that R1 was missing.
Report Continued on LIC 809-C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
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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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: AAA JERUSALEM STARS
FACILITY NUMBER: 195850306
VISIT DATE: 09/17/2024
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During the physical plant tour at 10:23AM, LPA observed the auditory exit alarm to R1’s room was turned off. Staff turned on the alarm during the visit and was functional and operating. During LPA’s interview with R1’s family, it was revealed that they have never heard the auditory exit alarm or observed the light on the device to be on. According to the family, they were not aware that one was installed as the device has been kept off and were only informed that there was a device when the LPA asked staff to turn on the alarm while family was visiting. Staff interviews revealed that the auditory device had just recently been turned off earlier in the day because the sliding exit door was opened to let a breeze in. Staff and Administrator were informed that the devices need to be on at all times. At 10:25AM, LPA observed the auditory exit alarm in the family room was turned off. Staff turned on the alarm during the visit and was functional and operating. At 10:26AM, LPA observed the living room to be missing an auditory exit alarm. Upon further inspection, LPA observed an uninstalled auditory exit device on the piano in the living room at 10:30AM.

Administrator was unable to remain at the facility for the delivery report. LPA delivered report to caregiver Ana Gutierrez who signed in the Administrator's place.

Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Administrator was informed that failure to correct deficiencies may result in civil penalties.

Exit interview conducted, report issued, and appeal rights provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/17/2024 02:48 PM - It Cannot Be Edited


Created By: Angela Barutyan On 09/17/2024 at 01:08 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 JERUSALEM STARS
FACILITY NUMBER: 195850306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/18/2024
Section Cited
CCR
87464(f)(1)(c)

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87464 Basic services (f)(1)(c) "Care and supervision" means the facility assumes responsibility for...ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered.
This requirement is not met as evidenced by:
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Administrator agreed to conduct an in-service training with staff to review section cited. In addition Licensee agreed to submit a letter of understanding to LPA via email by 09/18/2024 EOD.
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Based on interview and record review, the facility did not comply with the above cited section as R1 was able to leave the facility unassisted which posed an immediate risk to residents' safety.
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Type B
09/24/2024
Section Cited
CCR87705(c)(5)

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Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be... ensuring the following:(5)Each resident with dementia shall have an annual medical assessment...and a reappraisal...
This requirement is not met as evidenced by:
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Administrator agreed to obtain an updated medical assessment and perform a reappraisal of resident's needs and services. Administrator agreed to submit proof to CCL by 09/24/2024.
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Based on record review, the facility did not comply with the section cited above as R1 has dementia and does not have an updated medical assessment and reappraisal which poses a potential health, safety, and personal rights risk to resident in care.
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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:Angela Barutyan
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024


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Document Has Been Signed on 09/17/2024 02:48 PM - It Cannot Be Edited


Created By: Angela Barutyan On 09/17/2024 at 01:36 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 JERUSALEM STARS
FACILITY NUMBER: 195850306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/24/2024
Section Cited
CCR
87705(j)

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87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
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Administrator will ensure that auditory devices remain on at all times. Administrator agreed to install an auditory device to the sliding exit door in the living room and will submit proof to CCL by 09/24/2024.
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Based on observation, the licensee did not comply with the section cited above in that two (2) auditory exit alarms were observed off and one (1) exit door did not have an auditory device installed which poses a potential health and safety risk to persons in care.
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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:Angela Barutyan
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024


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