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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608972
Report Date: 06/28/2021
Date Signed: 06/28/2021 10:26:39 AM

Document Has Been Signed on 06/28/2021 10:26 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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ANTHEM SENIOR CAREFACILITY NUMBER:
197608972
ADMINISTRATOR:GHAZARYAN, SOFIAFACILITY TYPE:
740
ADDRESS:12813 FRIAR STREETTELEPHONE:
(818) 445-0993
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 6CENSUS: 5DATE:
06/28/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sofia Ghazaryan, AdministratorTIME COMPLETED:
11:00 AM
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During the physical plant tour on June 28, 2021 between 10:05 a.m. and 11:00 am., Licensing Program Analysts (LPAs) Salia Walker and Brian Balisi conducted an unannounced Plan of Correction visit to address deficiencies which were observed during the annual continuation visit conducted on June 18, 2021. LPAs met with administrator Sofia Ghazaryan at 10:05 a.m., and explained the reason for the visit.

During the physical plant tour on June 18, 2021 between 8:30 a.m. and 11:15 a.m., LPAs Salia Walker and Brian Balisi observed cameras were still installed in two (2) resident bedrooms. The LPAs also observed that the Activity room had remained converted into a resident bedroom, without the proper city permit through building and safety, or an approved fire clearance or an approval from Community Care Licensing. LPAs observed the bed was removed from Activity room at the time of the physical plant tour. The bed shall remain removed until the proper clearances have been obtained.

LPAs verbally informed the administrator to remove the cameras and it was noted on the LIC 809. On Monday June 21, 2021, administrator submitted photos of removed cameras from residents’ rooms.

During today’s visit, LPAs observed cameras were removed from two (2) resident bedrooms at 10:07 a.m. Administrator informed LPAs, the contractor visited the facility on scheduled date Monday the June 21, 2021 and removed all cameras that were installed in residents’ bedrooms.

Based on observation the following deficiencies were cleared (See LIC 809-D.) Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2021
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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