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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608349
Report Date: 10/05/2022
Date Signed: 10/05/2022 11:10:29 AM

Document Has Been Signed on 10/05/2022 11:10 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ABBEY ROAD VILLAFACILITY NUMBER:
197608349
ADMINISTRATOR:MARINE KARAPETIANFACILITY TYPE:
740
ADDRESS:14132 HUBBARD STREETTELEPHONE:
(818) 837-0077
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY: 78CENSUS: 54DATE:
10/05/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Marine Karapetyan - AdministratorTIME COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced case management visit at this facility to issue deficiency in conjunction with complaint control no.: 31-AS-20210204161317, wherein during the course of investigation regarding this complaint, it was found out that the staff did not abide by the facility's own fall protocol on the incident occurred on 09/30/20 wherein Resident #1 (R1) 1 had an unwitnessed fall.

Citation issued, appeal rights discussed and given.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2022
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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Document Has Been Signed on 10/05/2022 11:10 AM - It Cannot Be Edited


Created By: Jose Gary Tan On 10/05/2022 at 09:12 AM
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ABBEY ROAD VILLA
FACILITY NUMBER: 197608349

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/07/2022
Section Cited
CCR
87468.2(4)

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To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.

This requirement is not met as evidenced by:
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Administrator agreed to train all care staff with the above stated regulation and internal fall protocol and will submit proof of training on or before the POC date.
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Licensee failed to ensure that the staff abide by facility's own fall protocol which poses an immediate health and safety risk to the 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:Naira Margaryan
LICENSING EVALUATOR NAME:Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2022


LIC809 (FAS) - (06/04)
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