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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850323
Report Date: 11/01/2023
Date Signed: 11/01/2023 02:28:31 PM

Document Has Been Signed on 11/01/2023 02:28 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:COMFORT ZONE CALFACILITY NUMBER:
195850323
ADMINISTRATOR:TAVITIAN, HRIPSIME RIPAFACILITY TYPE:
740
ADDRESS:13303 REEDLEY STREETTELEPHONE:
(310) 430-0075
CITY:PANORAMA CITYSTATE: CAZIP CODE:
91402
CAPACITY: 6CENSUS: 6DATE:
11/01/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Akhtar Roshanaeian, LicenseeTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Deficiencies inspection. At 10:55 a.m., the LPA met with staff and explained the reason for the visit. At 12:34 p.m., the Licensee Akhtar Roshanaeian arrived at the facility.

The reason for today's inspection is to follow up on a self-reported incident dated 10/18/2023. The report pertains to the absent without official leave (AWOL) of Resident #1 (R1). On 10/17/2023, R1 left the facility despite caregivers attempting to redirect R1. The Administrator at the time notified R1’s family and the police. At the time of the visit, R1 still has not been located but the family are aware of the AWOL.

At 11:30 a.m., the LPA conducted a record review of resident records. At 1:30 p.m., the LPA, along with the Licensee conducted a brief physical plant tour. During the time of the visit, the LPA requested copies of pertinent documents.

Prior to visit, the LPA printed out the facility personnel report summary from the Licensing Information System (LIS). Upon arrival, it was revealed Staff #1 (S1) was recently hired. Per record review, conducted by the LPA on the Guardian Background Check System website, S1 does have fingerprint clearance but is not associated with this facility. Interviews with the Licensee and staff revealed that S1 started working at this facility on 11/01/2023. The Licensee stated that she will ensure that all staff will have a criminal record clearance and are associated to the facility prior to working at the facility.
During record review the following was noted: R1, Resident #2 (R2), Resident #3 (R3) and Resident #4 (R4) did not have resident files nor completed files available at the facility. Per incident report, R1 was admitted to the facility on 10/10/2023. R2 was admitted to the facility on 09/12/2023, R3 was admitted to the facility on 09/15/2023 and R4 was admitted to the facility on 10/31/2023. The Licensee stated that she will ensure that all residents will have completed files. Continued on LIC 809-C.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2023
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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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: COMFORT ZONE CAL
FACILITY NUMBER: 195850323
VISIT DATE: 11/01/2023
NARRATIVE
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Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 809-D). Civil Penalties assessed in the amount of $100. Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted. A copy of today's reports and appeal rights were provided. Civil penalties issued. An additional report may follow if warranted.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/01/2023 02:28 PM - It Cannot Be Edited


Created By: Emily Peraldi On 11/01/2023 at 01:50 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: COMFORT ZONE CAL
FACILITY NUMBER: 195850323

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/02/2023
Section Cited
CCR
87355(e)(2)

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87355(e)(2) Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health… shall prior to working... in a licensed facility: (2) Request a transfer of a criminal record clearance as specified... This requirement is not met as evidenced by:
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Licensee agreed to submit a transfer of a criminal record clearance for all staff not associated to the facility by 11/02/2023.

Civil Penalties assessed in the amount of $100.
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Based on record review and interview the Licensee did not comply with the section cited by not transferring the criminal record clearance for S1 to this facility prior to employment which poses an immediate health, safety and personal rights risk to persons in care.
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Type B
11/17/2023
Section Cited
CCR87506(a)

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87506(a) Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility…readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by:
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The Licensee stated that she will ensure that all residents will have completed files by due date.
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Based on record review, the Licensee did not comply with the section cited above as there were no files or incomplete files present at the facility for R1, R2, R3 and R4 which poses a potential health and safety risk to residents 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:Emily Peraldi
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2023


LIC809 (FAS) - (06/04)
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