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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609500
Report Date: 04/24/2021
Date Signed: 06/23/2021 01:03:48 PM

Document Has Been Signed on 06/23/2021 01:03 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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:DEVONSHIRE ELDERLY CAREFACILITY NUMBER:
197609500
ADMINISTRATOR:BANGASH, FARAHFACILITY TYPE:
740
ADDRESS:17441 DEVONSHIRE STREETTELEPHONE:
(310) 955-0674
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 6CENSUS: 3DATE:
04/24/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:16 PM
MET WITH:Farah Bangash - AdministratorTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Gary Tan conducted an unannounced case management visit at this facility in conjunction with the ongoing investigation with complaint control no. 31-AS-20200902164233 on 04/24/21. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted telephonically with Administrator Farah Bangash.

During the visit, LPA conducted virtual physical plant tour and interviewed the administrator. During the tour, LPA observed that the facility has screening station with PPE, hand sanitizer, thermometer and log. The staff are wearing mask while working in the facility. LPA also observed that the facility is generally clean and had sufficient food both perishable and non-perishable.

During the course of the investigation, LPA reviewed facility documents submitted by the administrator. LPA interview with the staff and administrator on 09/04/2020 revealed that Staff #1 (S1) was appointed as the Power of Attorney of Resident #1 (R1). LPA record review confirmed that S1 was indeed appointed as the power of attorney of Resident #1 (R1).

Citation issued. Appeal rights discussed and given.

Telephonic exit interview conducted. Copy of this report issued via email for signature.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2021
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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Document Has Been Signed on 06/23/2021 01:03 PM - It Cannot Be Edited


Created By: Jose Gary Tan On 04/24/2021 at 02:26 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: DEVONSHIRE ELDERLY CARE
FACILITY NUMBER: 197609500

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/29/2021
Section Cited
CCR
87217(d)(2)

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Except as provided in approved continuing care agreements, no licensee or employee of a facility shall:

accept any general or special power of attorney for any such person;

This requirement is not met as evidenced by:
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Administrator agreed to submit a written statement understanding the regulation cited and will submit to CCL on or before the POC date.
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Licensee did not ensure that any facility staff should not be appointed as POA of any resident. LPA record review and interview with administrator and staff revealed that S1 was appointed as the POA of a resident. This poses a potential personal rights to the 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.
SUPERVISOR'S NAME:Nichelle Gillyard
LICENSING EVALUATOR NAME:Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2021


LIC809 (FAS) - (06/04)
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