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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609500
Report Date: 03/10/2022
Date Signed: 03/10/2022 06:26:48 PM

Document Has Been Signed on 03/10/2022 06:26 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: 7DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Maria BangashTIME COMPLETED:
06:45 PM
NARRATIVE
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility in order to conduct a required 1 year annual visit. LPA's temperature was taken upon entry. The administrator designee arrived at about 5:50 PM.

Prior to beginning the infection control visit, LPA observed that there were seven (7) residents living at the facility. While touring the backyard, LPA observed that there was an un-associated person living in the backyard garage. LPA then toured the backyard and observed a laundry room with chemicals and tools accessible to residents. Next to the outside laundry facility, LPA also observed a hot tub with water in it and was accessible to the residents in care. There was no cover or gate to deny the accessibility to the hot tub.

LPA was unable to start or complete the Annual visit and a follow up visit will be required.

Exit interview conducted, deficiencies cited, and civil penalties issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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 03/10/2022 06:26 PM - It Cannot Be Edited


Created By: Patrick Shanahan On 03/10/2022 at 05:17 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: 03/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87204(a)
87204(a) Limitations-Capacity and Ambulatory Status. A licensee shall not operate a facility beyond the conditions and limitations specified on the license including the maximum number of persons who may receive services at any one time.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations the licensee did not comply with the section cited above as 7 residents were observed living at this facility which poses an immediate health, safety or personal rights risk to persons in care.
Civil Penalties 1548(c) Notwithstanding Section 1534, the department shall assess an immediate civil penalty of five hundred dollars and a one hundred dollar ($100) per day per violation for any of the following serious violations: (1) (A) Fire clearance violations, including, but not limited to, over capacity.
POC Due Date: 03/11/2022
Plan of Correction
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Administrator will put into writing her plan on how she will safely relocate the resident in care and remain in compliance and submit to the LPA by the POC date.
Type A
Section Cited
CCR
87355(e)(1)

87355(e)(1) Criminal Record Clearance. (e) ...shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above by allowing someone to rent and live in the converted garage which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2022
Plan of Correction
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The administrator notified the person in the backyard that they are not to be in the garage until they have been finger print cleared. The administrator will also submit a facility sketch that outlines that the garage is now an apartment. An immediate civil penalty of $500 assessed for zero tolerance violation.
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:Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/10/2022 06:26 PM - It Cannot Be Edited


Created By: Patrick Shanahan On 03/10/2022 at 05:35 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: 03/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(e)

Personal Accommodations and Services. Facilities providing services...physical or mental disabilities... assure the inaccessibility of ... swimming pools,... water, when not in active use by residents... through fencing...means. This requirement is not met as evidenced by
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 by making the hot tub inaccessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2022
Plan of Correction
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The administrator will drain the water, cover or fence the hot tub and submit photos to the LPA as POC.
immediate civil penalty of $500 assessed for zero tolerance violation.
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022


LIC809 (FAS) - (06/04)
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