<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609500
Report Date: 10/09/2024
Date Signed: 10/09/2024 12:48:02 PM

Document Has Been Signed on 10/09/2024 12:48 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:DEVONSHIRE ELDERLY CAREFACILITY NUMBER:
197609500
ADMINISTRATOR/
DIRECTOR:		BANGASH, FARAHFACILITY TYPE:
740
ADDRESS:17441 DEVONSHIRE STREETTELEPHONE:
(310) 955-0674
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 6CENSUS: 6DATE:
10/09/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Maria BangashTIME VISIT/
INSPECTION COMPLETED:
12:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/09/24, at 9:00am Licensing Program Analyst (LPAs) Gina Saucedo, Angelica Segovia and Licensing Program Manager (LPM) Troy Agard conducted an unannounced visit to this facility for deficiencies.

During the Physical Tour and Records Review, LPA's and LPM observed:

A health screening was missing for one (1) of the staff currently working/associated with the above facility.
A Physician's Report was missing not showing the tuberculosis screening for one (1) of the residents.
The Facility was in disrepair missing ceiling panels in the kitchen, the fireplace covering has to be attached a broken sliding door in one (1) of the resident's room is broken and a broken door leading to the entrance/exit of the facility has to be repaired.
A staff that does not have the proper documentation/association to work at the above facility.


Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC 809D.

Exit interview conducted, appeal rights and copy of report signed and delivered to the Administrator.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2024
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 10/09/2024 12:48 PM - It Cannot Be Edited


Created By: Gina Saucedo On 10/09/2024 at 09:59 AM
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: 10/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/09/2024
Section Cited
CCR
87303(a)

1
2
3
4
5
6
7
87303 (a)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:
1
2
3
4
5
6
7
The licensee/administrator shall repair the ceiling panel in the kitchen, the fireplace covering to be attached and the broken sliding door in the resident's room, the broken door to the entrance/exit of the facility by POC due date: 10/23/24. The licensee/administrator shall send a picture/repair paperwork to the LPA.
8
9
10
11
12
13
14
Based on the LPA observation and interviews the licensee/administrator did not ensure four (4) out of four (4) damages at the facility to be in repaired at all times which poses a Potential Health, Safety or Personal Rights risks to persons in care.
8
9
10
11
12
13
14
Type B
10/09/2024
Section Cited
CCR87458(b)(1)

1
2
3
4
5
6
7
87458(b)(1)-The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis/secondary diagnosis,...results of an examination for communicable tuberculosis, other diseases...This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The licensee/administrator shall have and retain the proper paperwork for each resident for three (3) years and send copy of tuberculosis to the LPA by
POC due date: 10/23/24
8
9
10
11
12
13
14
Based on the LPA observation and interviews the licensee/administrator did not ensure one (1) out of six (6) residents to have their Physican's Report and tuberculosis paperwork which poses a Potential Health, Safety or Personal Rights risks to persons in care.
8
9
10
11
12
13
14
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:Troy Agard
LICENSING EVALUATOR NAME:Gina Saucedo
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/09/2024 12:48 PM - It Cannot Be Edited


Created By: Gina Saucedo On 10/09/2024 at 11:02 AM
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: 10/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/09/2024
Section Cited
CCR
87411(f)

1
2
3
4
5
6
7
87411(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.This
requirement is not met as evidenced by:
1
2
3
4
5
6
7
The licensee/administrator shall have and retain the proper paperwork for each staff and send a copy of health screening to the LPA by
POC due date: 10/23/24
8
9
10
11
12
13
14
Based on the LPA observation and interviews the licensee/administrator did not ensure one (1) out of five (5) staff had a health screening which poses a Potential Health, Safety or Personal Rights risks to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Troy Agard
LICENSING EVALUATOR NAME:Gina Saucedo
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/09/2024 12:48 PM - It Cannot Be Edited


Created By: Gina Saucedo On 10/09/2024 at 11:25 AM
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: 10/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/09/2024
Section Cited
CCR
87355(e)(1)

1
2
3
4
5
6
7
Criminal Clearance 87355(e)(1) 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: (1)Obtain a California clearance or a criminal record exemption as required by the Department This requirement is not met as evidenced by:
1
2
3
4
5
6
7
LPA requested adminstrator to remove the individual from the facility area as soon as possible. Within 24 hours licensee must inform RO that the individual is removed and will not return to facility without criminal record clearance and association. A $500.00 civil penalty will be assessed at the time of this visit.
8
9
10
11
12
13
14
Licensee failed to obtain criminal clearance/background association for an indvidual that is currently working as a staff which poses an Immediate Health, Safety or Personal Rights risks to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Troy Agard
LICENSING EVALUATOR NAME:Gina Saucedo
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024


LIC809 (FAS) - (06/04)
Page: 4 of 4