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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609559
Report Date: 08/25/2021
Date Signed: 08/25/2021 04:50:54 PM

Document Has Been Signed on 08/25/2021 04:50 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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ANO ONE FACILITY FOR THE ELDERLYFACILITY NUMBER:
197609559
ADMINISTRATOR:ATOYAN, ARTURFACILITY TYPE:
740
ADDRESS:7907 STANSBURYTELEPHONE:
(818) 616-2390
CITY:PANORAMA CITYSTATE: CAZIP CODE:
91402
CAPACITY: 6CENSUS: 4DATE:
08/25/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH: ARTUR ATOYANTIME COMPLETED:
05:00 PM
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Licensing Program Analysts (LPAs) Emily Peraldi and Ashley Smith conducted an unannounced Case Management-Deficiencies inspection visit at the facility today due to deficiencies observed during the investigation of complaint control # 29-AS-20210809155552.

At 11:36 a.m., LPA Peraldi toured the facility. The LPA observed accessible chemicals in the bathroom cabinets. During a previous visit conducted on 08/17/2021, the LPA toured the facility and observed over the counter medications and disinfectants accessible in restrooms. Items were secured upon observation.

At 11:41 a.m., the LPAs interviewed Administrator ARTUR ATOYAN. Administrator stated that Resident #1 (R1) went to a skilled nursing facility a few months ago. Per record reviews, R1 was sent to the hospital and transferred to a skilled nursing facility from 06/10/2021 to 06/29/2021. The facility did not send an Incident Report for either unusual incidents.

During a previous visit conducted on 08/17/2021, staff mentioned to LPA Peraldi that Resident #2 (2) had passed away a few weeks ago. LPA Peraldi asked Administrator about the death and Administrator stated that R2 passed away on 08/08/2021. The death was never reported to the Department. LPA Peraldi requested for a copy of the death report. Administrator stated that they believed that the time frame to submit a death report was ten (10) days. LPA pointed out that the death report states to submit the written report within seven (7) days of occurrence.

At 11:31 a.m., LPA Peraldi observed a camera in Resident #3’s (R3) room. Per interviews, Administrator confirmed that the camera is there for additional oversight.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):
Exit interview conducted, today's reports and appeal rights were reviewed and issued.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2021
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 08/25/2021 04:50 PM - It Cannot Be Edited


Created By: Emily Peraldi On 08/25/2021 at 02:40 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANO ONE FACILITY FOR THE ELDERLY
FACILITY NUMBER: 197609559

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/25/2021
Section Cited
CCR
87705(f)(2)

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87705 (f)(2)Care of Persons with Dementia The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances ...
This requirement is not met as evidenced by:
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These items were secured upon observations. Plan of correction met.
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Based on observations, the licensee did not comply with the section cited above, as medications and disinfectants were accessible, which poses an immediate health and safety risk to residents in care.
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Type A
08/25/2021
Section Cited
CCR87468.2(a)(1)

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87468.2 (a)(1) Additional Personal Rights of Residents in Privately Operated Facilities. Residents...shall have the following personal rights: To have a reasonable level of personal privacy in accommodations, medical treatment, personal care...
This requirement is not met as evidenced by:
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During todays visit, the licensee removed the camera. Plan of correction met.
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Based on observations and interview, the licensee did not comply with the section cited above, as there was a camera in one out of four resident rooms (R3), which poses an immediate personal rights risk to 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:Kristin Heffernan
LICENSING EVALUATOR NAME:Emily Peraldi
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2021


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/25/2021 04:50 PM - It Cannot Be Edited


Created By: Emily Peraldi On 08/25/2021 at 02:59 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANO ONE FACILITY FOR THE ELDERLY
FACILITY NUMBER: 197609559

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/25/2021
Section Cited
CCR
87211(a)(1)(D)

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87211(a)(1)(D) Reporting Requirements. A written report shall be submitted to the licensing agency ... within seven days of the occurrence: Any incident which threatens the welfare, safety or health of any resident.
This requirement is not met as evidenced by:
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The Administrator agreed to the following:
Submit incident report for R1 and updated death report for R2 by 08/30/2021.
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Based on interview and record review, the licensee did not comply with the section cited above, as an incident report was not submitted for R1's hospitalization or R2's death in a timely manner, which poses a potential health and safety risk to 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:Kristin Heffernan
LICENSING EVALUATOR NAME:Emily Peraldi
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2021


LIC809 (FAS) - (06/04)
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