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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608927
Report Date: 08/29/2022
Date Signed: 08/30/2022 03:17:06 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/23/2022 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20220823100236
FACILITY NAME:JUST LIKE HOME IIFACILITY NUMBER:
197608927
ADMINISTRATOR:MARAT DAVIDIANFACILITY TYPE:
740
ADDRESS:13524 CHANDLER BLVD.TELEPHONE:
(818) 769-9955
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91423
CAPACITY:6CENSUS: 6DATE:
08/29/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:MARAT DAVIDIANTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Facility does not follow COVID-19 health and safety protocol.
INVESTIGATION FINDINGS:
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On 08/29/2022, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced visit to investigate the allegation named above. LPA Urena arrived at the facility at 10:30 a.m., met with the administrator Marat Davidian and explained the reason for the visit.

At 10:45 a.m., the LPA, and the staff conducted a brief tour of the facility. No deficiencies were noted during the tour of the facility.

Continues on LIC 9099 C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 29-AS-20220823100236
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: JUST LIKE HOME II
FACILITY NUMBER: 197608927
VISIT DATE: 08/29/2022
NARRATIVE
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Regarding the allegation, ‘Facility does not follow COVID-19 health and safety protocol’, it is the concern of the Reporting Party (RP) that the facility has not been safeguarding residents by not practicing proper infection control. At 10:30 a.m., the LPA arrived at the facility and was allowed inside the facility by caregivers without conducting infection control practices. At 10:45 a.m., the administrator and the LPA conducted the tour of the facility, and noticed that at the entrance of the common area , there was a table with an oral thermometer, a sign in book and, and an alcohol bottle. The LPA brought to the attention of the administrator the thermometer, and explained that is was not the correct thermometer for conducting infection control practices. The administrator asked the staff for 'the other thermometer' and the staff brought out of the medication closet, a digital thermometer. The administrator and staff were also instructed to place masks on the table with the other items, in case a visitor came to the facility without a mask/face covering. Additionally, the LPA instructed staff, and administrator to follow current infection control guidelines, which state that all visitors must be screened.

Additionally, the LPA asked the staff if an an outside agency had visited the facility recently, and had brought to their attention conducting an initial screening for COVID-19 symptoms of all individuals entering facility? The staff stated that 'yes' an outside agency had visited a few weeks ago.

Based on the LPA’s observation, and interview with the administrator, there is sufficient evidence to support the allegation that the 'Facility does not follow COVID-19 health and safety protocol’. Therefore, this allegation is deemed Substantiated at this time.



The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview was conducted with facility representative, a copy of the report, and Appeal Rights were issued.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20220823100236
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: JUST LIKE HOME II
FACILITY NUMBER: 197608927
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/09/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1(a)(2) 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: (2) To be accorded safe, healthful and comfortable accommodations...
This requirement is not met as evidenced by:
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Submit staff training sign in sheet and supporting documentation on Infection Control Practices- PIN 21-38-ASC regarding masks wearing in the facility to LPA by 09/02/2022.
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Based on observation, and interviews conducted, the Licensee did not comply with the section cited above, staff did not conduct initial screening for COVID-19 symptoms of individuals entering facility, while providing care and supervision to residents in care, 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.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022
LIC9099 (FAS) - (06/04)
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