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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609357
Report Date: 12/08/2022
Date Signed: 12/08/2022 04:08:37 PM

Document Has Been Signed on 12/08/2022 04:08 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:BIRMINGHAM VILLAFACILITY NUMBER:
197609357
ADMINISTRATOR:LEKHLYAN, ANAHITFACILITY TYPE:
740
ADDRESS:825 BIRMINGHAM RDTELEPHONE:
(818) 859-7777
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY: 6CENSUS: 6DATE:
12/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:38 PM
MET WITH:Christina LekhlanTIME COMPLETED:
04:19 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required One (1) year - Inspection to this facility. Upon arrival, LPA met with staff Susanna Hayrapetyan who assisted with the visit. Shortly after Administrator Christine Lekhlyan arrived. The purpose of the visit was explained. The facility is licensed to serve 6 (six) non-ambulatory residents. Hospice Waiver for (3) three residents. Residents receive services from the Frank D. Lanterman Regional Center.
LPA used the infection control tool to evaluate the facility. LPA inspected the physical plant, COVID-19 procedures, ,. Facility has submitted a mitigation plan and the plan has been approved. Last fire drill was 10.28.2022

Facility is located in a residential neighborhood and consists of (6) six resident bedrooms, (1) one staff bedroom, (3) three bathrooms, kitchen, living room, dining room, laundry room area, office area.

LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards. LPA observed that the facility does not have a swimming pool or other bodies of water. All indoor and outdoor passageways are free of obstruction.

There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. Two staff were observed not wearing mask during this visit.



Resident bedrooms and bathrooms were toured. All bedrooms were sanitary and furnished with required furniture Room 6 had broken dresser and room 3 had window screen in disrepair. Bathrooms have the required grabs bars and non-skid mats. The hot water temperature was tested throughout the facility and maintained within the range of 106.4 -140*F which is out of range. Hole in the wall behind dryer was observed.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 12/08/2022 04:08 PM - It Cannot Be Edited


Created By: Alberto Lopez On 12/08/2022 at 03:30 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BIRMINGHAM VILLA
FACILITY NUMBER: 197609357

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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 in 2 out of 2 STAFF that LPA observed not wearing mask at facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/09/2022
Plan of Correction
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Staff put on mask during the visit. Administrator will conduct training on personal rights and infection control for all and send signed roster to LPA by POC date.
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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. LPA tested water in kitchen tab and it measured 140 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/09/2022
Plan of Correction
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Administrator will address the facet with the tab hot water and send a written plan of how it is addressed by POC to LPA.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/08/2022 04:08 PM - It Cannot Be Edited


Created By: Alberto Lopez On 12/08/2022 at 03:30 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BIRMINGHAM VILLA
FACILITY NUMBER: 197609357

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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. LPA and administrator observed broken dresser in room #6, torn screen in room #3 and hole in the wall behind the gas dryer which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/15/2022
Plan of Correction
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Administrator will repair or replace dresser in room 6, repair hole in the wall and repair screen in room #3 by POC date and send proof to LPA by 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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022


LIC809 (FAS) - (06/04)
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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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BIRMINGHAM VILLA
FACILITY NUMBER: 197609357
VISIT DATE: 12/08/2022
NARRATIVE
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The following were observed/inspected:

· COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept.
· Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote handwashing, cough/sneeze etiquette, and physical distancing.
· Facility does not have designated isolation room as clients have private rooms and can isolate there.
· common areas, bathrooms, and outdoor physical plant was inspected.
· Four (4) centrally stored client medication records were reviewed.
· Staff responsible for direct care and supervision were not observed wearing mask initially but put them on during visit. Food supplies for 7 days of nonperishable and 2 days perishable were observed at facility. A posted Emergency Disaster Plan was observed posted at facility.
· PPE's were observed.
· Staff and resident files were not reviewed during today's visit.
· Deficiencies cited per Title 22 Health and safety code, see 809D for details.

Exit interview was conducted with Administrator Christine Lekhlyan, A copy of the report and appeal rights were. provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
LIC809 (FAS) - (06/04)
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