Community Care Licensing

Document Has Been Signed on 02/21/2025 02:10 PM - It Cannot Be Edited

FACILITY NAME:	THREE SYCAMORES ON GOULD		FACILITY NUMBER:	197607355
ADMINISTRATOR/ DIRECTOR:	MARK YULE		FACILITY TYPE:	740
ADDRESS:	4701 GOULD AVENUE		TELEPHONE:	(818) 952-0491
CITY:	LA CANADA	STATE: CA	ZIP CODE:	91011
CAPACITY: 6		CENSUS: 3	DATE:	02/21/2025
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:10 AM
MET WITH:	Assistant Administrator, Sean Draeco Abalajon & Caregiver Rachelle Gonzales		TIME VISIT/ INSPECTION COMPLETED:	02:15 PM

SUPERVISORS NAME: Naira Margaryan LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2025

Link to Parent Document Below:

FACILITY NAME: THREE SYCAMORES ON GOULD	FACILITY NUMBER: 197607355
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/21/2025

Type A

Section Cited

CCR

87307(d)(6)

87307(d)(6) Personal Accommodations and Services. All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: The licensee did not ensure that outdoor passageways are free of obstruction.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above there are several pieces of lumber with sharp edges leaning against back wall of the facility which poses an immediate health, safety risk to persons in care.
	POC Due Date: 02/22/2025
	Plan of Correction
1 2 3 4	At the time of visit lumber was removed and POC cleared on 02/21/2025.

Type A

Section Cited

CCR

87208

87208 Plan of Operation The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation This requirement is not met as evidenced by: The licensee failed to follow their own plan of operation.
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above facility retains two (02) hospice residents, but hospice waiver is approved for 1. This possess an immediate health and safety hazard to clients in care.
	POC Due Date: 02/22/2025
	Plan of Correction
1 2 3 4	Licensee will submit a hospice waiver/acception to CCL or remove resident from facility by POC due date.

SUPERVISOR'S NAME: Naira Margaryan LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2025

Link to Parent Document Below:

FACILITY NAME: THREE SYCAMORES ON GOULD	FACILITY NUMBER: 197607355
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/21/2025

Type A

Section Cited

CCR

87303(a)

87303 Maintenance and Operation. (a)The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by: Gate leading outside was broken.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above licensee did not ensure that the facility is in good repair. Facility retains dementia residents and one (01) of the gates leading outside was broken. This possess an immediate health and safety to residents in care.
	POC Due Date: 02/22/2025
	Plan of Correction
1 2 3 4	At the time of visit the broke gate was repaired and POC cleared on 02/21/2025.

Type A

Section Cited

CCR

87303(b)

87303 Maintenance and Operation. (b) A comfortable temperature for residents shall be maintained at all times. This requirement is not met as evidenced by: Licensee did not ensure that facility temperature is comfortable for all residents.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above the thermostat was broken for a while and the rooms were heated by portable heaters which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/22/2025
	Plan of Correction
1 2 3 4	Licensee will submit proof of thermostat repaired by POC due date.

SUPERVISOR'S NAME: Naira Margaryan LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2025

Link to Parent Document Below:

FACILITY NAME: THREE SYCAMORES ON GOULD	FACILITY NUMBER: 197607355
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/21/2025

Type B

Section Cited

CCR

87405(d)(2)

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by: Licensee did not ensure that the facility has qualified Administrator.
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above that the facility has qualified Administrator that could confirm applicable law, rules and regulations. Facility in noncompliance with title 22 regulations leading to serious deficiencies which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/12/2025
	Plan of Correction
1 2 3 4	Licensee will submit a written document to LLC indicating that reviewed and understood all the deficiencies that were issued by POC due date.

Type B

Section Cited

CCR

87555(27)

87555 General Food Service Requirements (27) All … areas shall be kept clean and free of litter, rodents, vermin, and insects. This requirement is not met as evidenced by: Licensee did not ensure that the facility is free of vermin.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above LPA was informed that there are rat droppings in the facility which poses a potential health, safe risk to persons in care.
	POC Due Date: 03/12/2025
	Plan of Correction
1 2 3 4	Licensee will submit proof of pest control invoice to CCL by due date.

SUPERVISOR'S NAME: Naira Margaryan LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2025

Link to Parent Document Below:

FACILITY NAME: THREE SYCAMORES ON GOULD	FACILITY NUMBER: 197607355
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/21/2025

Type B

Section Cited

CCR

7506(a)

7506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility. This requirement is not met as evidenced by: Residents records were missing information.
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above documents on the records identify other facilities names. Physician reports were not signed by the doctors which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/12/2025
	Plan of Correction
1 2 3 4	Licensee will submit a complete physician report for each resident to CCL by POC due date.

Section Cited

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

SUPERVISOR'S NAME: Naira Margaryan LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2025

Link to Parent Document Below:

FACILITY NAME: THREE SYCAMORES ON GOULD	FACILITY NUMBER: 197607355
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/21/2025

Type A

Section Cited

HSC

1569.1(a)(1)

H &S Code1569.73(a) (1) The facility agrees to retain the terminally ill resident, …and to seek a waiver on behalf of the individual…, provided the individual…is capable of deciding to obtain hospice services. This requirement is not met as evidenced by: Facility retains two (02) hospice residents but is approved for one (01) hospice waiver.
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above facility retains two (02) hospice residents. Hospice waiver is approved for one (01) resident which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/22/2025
	Plan of Correction
1 2 3 4	Licensee will submit hospice waiver/accept to CCL for approval by POC due date.

Section Cited

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

SUPERVISOR'S NAME: Naira Margaryan LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2025