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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608972
Report Date: 05/17/2022
Date Signed: 05/17/2022 12:30:24 PM

Document Has Been Signed on 05/17/2022 12:30 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
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: 4DATE:
05/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Sofiya GhazaryanTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a required Annual visit. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Sofiya Ghazaryan and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside, with the Administrator to ensure there are no health and safety hazards.

BEDROOMS: There are (4) four bedrooms designated for resident use and (1) one bedroom designated for staff use. The facility has converted the garage into a separate living quarters which has its own address. The Administrator agreed to submit a new facility sketch to the department. The facility has furnished each room with clean linens, appropriate furnishings, and sufficient lighting for resident use. The LPA observed one staff bedroom and one designated resident room to have undergone water damage. The Administrator explained that it was recently discovered that a water line behind the refrigerator had been leaking causing unknown water damage that reached an adjacent staff bathroom bedroom and unoccupied resident bedroom. The Administrator reported that this issue is being addressed by the insurance company and is in the process of conducting repairs due to the water damage.

RESTROOMS: The LPA observed Resident restrooms to be clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap and paper products. The LPA observed the staff bathroom to be undergoing repairs due to water damage resulting from a broken refrigerator water hose. Restroom hot water measured between 119.4 and 120.0 degrees Fahrenheit between 10:06 a.m. and 10:19 a.m. The LPA suggested to the Administrator to turn down the water heater temperature to ensure compliance.



Continued on LIC 809-C
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANTHEM SENIOR CARE
FACILITY NUMBER: 197608972
VISIT DATE: 05/17/2022
NARRATIVE
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KITCHEN: At 9:50 a.m. the LPA observed the kitchen to be undergoing repairs with kitchen cabinet drawers removed. The LPA observed Knives are stored in a locked cabinet in the kitchen. Kitchen appliances were in operable condition at the time of the visit. The facility has enough supply of perishable and non-perishable food. Freezer and refrigerator are stocked with a variety of foods. Although the kitchen is going through repairs due to water damage the facilities ability to prepare foods and use the kitchen sink have gone uninterrupted. The LPA observed cleaning supplies and disinfectants unlocked under the kitchen sink.

COMMON AREAS: The common spaces included the living room and dining area. The LPA observed cameras in all common spaces and a screened fireplace in the living room. All areas were clean, sanitary and in good repair. The LPA observed required postings on the living room wall. One fire extinguisher was observed to be fully charged and serviced on 11/15/2021. Smoke detectors and Carbon Monoxide detectors are hardwired and interconnected, however at 10:24 a.m. the LPA tested the system and observed that only one alarm was functioning. The LPA advised the Administrator that this would need to be repaired immediately.

BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use and a small laundry area. There were no bodies of water noted. The garage is attached to the house but has been converted to a separate living quarters for the administrator with a separate address.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator Sofiya Ghazaryan regarding the facility’s infection control practices. The Administrator was advised that they need to ensure that visitors upon entry are signing in at a central entry point for symptom screening, temperature checks, and sanitation. The LPA also advised the Administrator to ensure staff continue wearing face masks at all times. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time and the LPA reviewed facility’s policies and procedures as it pertains to infection control.

Continued on LIC 809-C

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
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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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANTHEM SENIOR CARE
FACILITY NUMBER: 197608972
VISIT DATE: 05/17/2022
NARRATIVE
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The Administrator advised the LPA that they are waiting on insurance to assess the water damages. This inspection is expected in the next day or two. At this time there is no date of repairs but will update the assigned LPA on the progress of the repairs. At this time the Administrator indicated that all meals and use of the kitchen appliances are uninterrupted.


The following deficiencies were observed (See LIC 809-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 conducted. A copy of the report and appeal rights were provided via Email.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
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Document Has Been Signed on 05/17/2022 12:30 PM - It Cannot Be Edited


Created By: Elsie Campos On 05/17/2022 at 11:47 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANTHEM SENIOR CARE
FACILITY NUMBER: 197608972

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Maintenance and Operation
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as cleaning solutions were observed to be unlocked under the kitchen sink which poses a potential health and safety risk to persons in care.
POC Due Date: 05/17/2022
Plan of Correction
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The Administrator agreed to the folllowing:
1. To secure any and all cleaning solutions. POC cleared at time of the visit.
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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Elsie Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 05/17/2022 12:30 PM - It Cannot Be Edited


Created By: Elsie Campos On 05/17/2022 at 11:47 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANTHEM SENIOR CARE
FACILITY NUMBER: 197608972

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
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, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as in two staff were not wearing face masks as required which poses a potential health and safety risk to persons in care.
POC Due Date: 05/17/2022
Plan of Correction
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The administrator agreed to do the following:
1. Ensure that all staff continue to wear maks when in the facility. POC cleared at time of the visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Elsie Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022


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Page: 5 of 10
Document Has Been Signed on 05/17/2022 12:30 PM - It Cannot Be Edited


Created By: Elsie Campos On 05/17/2022 at 12:00 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: ANTHEM SENIOR CARE
FACILITY NUMBER: 197608972

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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Based on observation, the licensee did not comply with the section cited above as the fire alarm system at time of testing was inoperable which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/20/2022
Plan of Correction
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The adminsitrator agreed to the following:
2. Submit proof of repairs to CCL no later than the POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Elsie Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022


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