Community Care Licensing

Document Has Been Signed on 06/16/2023 04:28 PM - It Cannot Be Edited

FACILITY NAME:	ANTHEM SENIOR CARE		FACILITY NUMBER:	197608972
ADMINISTRATOR:	GHAZARYAN, SOFIA		FACILITY TYPE:	740
ADDRESS:	12813 FRIAR STREET		TELEPHONE:	(818) 445-0993
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY: 6		CENSUS: 5	DATE:	06/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Sofia Ghazaryan, Administrator		TIME COMPLETED:	04:40 PM

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel LICENSING EVALUATOR NAME: Christine Yee LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2023

Link to Parent Document Below:

FACILITY NAME: ANTHEM SENIOR CARE	FACILITY NUMBER: 197608972
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/16/2023

Type A

Section Cited

CCR

87411(f)

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above in 3 out of 3 records requested, per Licensee, the Physician's report are somewhere and could not be provided to LPA for review and which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/07/2023
	Plan of Correction
1 2 3 4	Licensee will ensure that all employees are in good health and physically and mentally capable of performing assigned task. Good physical health shall be verified by a health screening, including a chest x-ray or intradermal test performed by a physician not more than 6 months prior to seven days after employment or licensure. The Licensee will provide evidence that the health screening with the results of a TB test was completed by 7/7/23

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel LICENSING EVALUATOR NAME: Christine Yee LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2023

Link to Parent Document Below:

FACILITY NAME: ANTHEM SENIOR CARE	FACILITY NUMBER: 197608972
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/16/2023

Type A

Section Cited

CCR

87355(e)

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above in 1 out of 3 records reviewed, which poses an immediate health, safety or personal rights risk to persons in care. Susan Roberts, Backup Administrator was present at the facility on today's visit and was not able to provide evidence that a criminal record clearance was obtained and was not associated to the facility as of today's visit. Immediate civil penalties were assessed.
	POC Due Date: 06/17/2023
	Plan of Correction
1 2 3 4	The Licensee will provide a written plan as to how the Licensee will ensure that all employees and individuals who require a criminal record clearance obtain one and are associated to the facility prior to being present at the facility by 6/17/23. Licensee will also notify Licensing once the clearance for is completed. IMMEDIATE CIVIL PENALTIES ASSESSED

Section Cited

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

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel LICENSING EVALUATOR NAME: Christine Yee LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2023

Link to Parent Document Below:

FACILITY NAME: ANTHEM SENIOR CARE	FACILITY NUMBER: 197608972
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/16/2023

Type B

Section Cited

CCR

87303(e)(5)

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in 1 out of 2 bathrooms inspected, the common bathroom in the back did not have a non-skid mat, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/23/2023
	Plan of Correction
1 2 3 4	Licensee will purchase a non-skid mat for the common bathroom located in the back of facility. Licensee will provide evidence that a non-skid mat was purchased and placed in the bathroom.

Type B

Section Cited

CCR

87412(a)

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 3 out of 3 files requested for review and was informed that the facility does not have files for the 3 staff, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/07/2023
	Plan of Correction
1 2 3 4	Per discussion with the Licensee/Administrator, due to the Backup Administrator being out of town, addtional time is needed to create files containing the required document for each employee, including the Administrator

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel LICENSING EVALUATOR NAME: Christine Yee LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2023

Link to Parent Document Below:

FACILITY NAME: ANTHEM SENIOR CARE	FACILITY NUMBER: 197608972
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/16/2023

Type B

Section Cited

CCR

87411(c)(6)

(6) The licensee shall maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2). For on-the-job training, documentation shall consist of a statement or notation, made by the trainer, of the content covered in the training. Each item of documentation shall include a notation that indicates which of the criteria of Section 87411(c)(3) is met by the trainer. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 3 out of 3 files requested for review/evidence of staff training and was advised that training logs are not kept by the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/07/2023
	Plan of Correction
1 2 3 4	Licensee will submit a written plan indicating how the facility will ensure that all staff training are recorded and contains the following information - date of training, subject of the training, material covered, hours of training provided and the name of the trainer. Provide LPA with the written plan by 7/7/23.

Section Cited

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

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel LICENSING EVALUATOR NAME: Christine Yee LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2023

FACILITY NAME: ANTHEM SENIOR CARE	FACILITY NUMBER: 197608972
	VISIT DATE: 06/16/2023