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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609500
Report Date: 03/24/2022
Date Signed: 03/24/2022 03:26:41 PM

Document Has Been Signed on 03/24/2022 03:26 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: 5DATE:
03/24/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Farah Bangash, Administrator.TIME COMPLETED:
03:40 PM
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An unannounced Plan of Correction (POC) visit was conducted on this day by Licensing Program Analysts (LPAs) Angela Panushkina and Melissa Ruiz. The purpose of this visit is to follow up on the pending Plan of Corrections (POCs) that were issued during the complaint visit conducted on 03/16/22 by LPAs Melissa Ruiz and Joselyn Martinez.

Upon arrival to the facility LPA's met with Farah Bangash.

The Licensing Report issued on 03/16/22 gave notice to the licensee that failure to correct the cited deficiencies within a specified length of time would result in civil penalties being issued.


From 10:20am to 11:30am a physical plant tour was conducted with the Designee, Maria Bangash.

LPAs informed the Administrator the deficiencies were cleared. At 3:00pm, LPA Panushkina emailed the POC letter via email to the Administrator.


87705 (f)(1)(2) Care of Persons with Dementia. POC submitted on 03/20/22

87204(a) Limitations-Capacity and Ambulatory Status. POC submitted on 03/16/22

87411(a) Personnel Requirements-General. POC submitted on 03/20/22

87506(a) Resident Records. POC submitted on 03/20/22 Continue on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2022
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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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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: DEVONSHIRE ELDERLY CARE
FACILITY NUMBER: 197609500
VISIT DATE: 03/24/2022
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87506(c)(1) Resident Records. POC submitted on 03/20/22

87303(a) Maintenance and Operation. POC submitted on 03/20/22

87307(d)(2) Personal Accommodations and Services. POC submitted

Exit interview conducted and copy of this report was emailed to the Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022
LIC809 (FAS) - (06/04)
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