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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197609731
Report Date:
09/17/2024
Date Signed:
09/23/2024 11:41:58 AM
Document Has Been Signed on
09/23/2024 11:41 AM
- 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:
G & A CARE
FACILITY NUMBER:
197609731
ADMINISTRATOR/
DIRECTOR:
KOSOYAN, GRIGOR
FACILITY TYPE:
740
ADDRESS:
16301 NORDHOFF STREET
TELEPHONE:
(323) 314-2996
CITY:
NORTH HILLS
STATE:
CA
ZIP CODE:
91343
CAPACITY:
6
CENSUS:
2
DATE:
09/17/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:
KOSOYAN, GRIGOR- Licensee
TIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an annual required visit and inspection of the facility. At 10:00 am Markui Kosayan who is the mother of the licensee met with LPA. At 10:24 AM Grigor Kosoyan who is the licensee arrived at the facility and met with the LPA and was explained the reason for the visit. A civil penalty will be issued since no staff was seen to be present when LPA arrived.
At 10:25 AM, with the assistance of licensee, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are operational that are located each bedroom, the hallway and kitchen. There are carbon monoxide detectors that functions properly. The fire extinguisher is in the kitchen. The charge date is 11/30/2023. During the visit the facility is at 72 degrees Fahrenheit. The facility is fire cleared for six (06) non-ambulatory residents; 1 bedridden; hospice waiver for 5.
Kitchen:
The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked drawer in the kitchen. The menu was posted for review. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Cleaning supplies, pesticides or toxic cleaning supplies were stored and was kept unlock in the laundry. LIC 809-D will be cited on deficiency page.
Bedrooms:
There were four (4) bedrooms designated for residents' use. Bedroom #1 is for private and vacant; bedroom #3 is for private use. Bedroom #4 is shared and vacant. Bedroom #2 is shared and is currently being only occupied by one resident. Resident bedrooms were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting.
Continue to LIC 809-C
SUPERVISORS NAME
:
Nichelle Gillyard
LICENSING EVALUATOR NAME
:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE
:
DATE:
09/17/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/17/2024
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
WOODLAND HILLS S.RO
,
21731 VENTURA BLVD., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
G & A CARE
FACILITY NUMBER:
197609731
VISIT DATE:
09/17/2024
NARRATIVE
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Bathrooms:
There are two (2) bathroom at the facility, one for staff and the other one is designated for residents' use. The bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 105.2 degrees Fahrenheit for bathroom #1 located in the hallway beside room #2. Staff bathroom is located by the entrance of the facility. There was enough clean linen available in the cabinets in the hallway.
Common Areas:
LPA toured all common areas of the facility. These included the living room and dining area for residents. The common areas were properly furnished. Residents dining table fits enough for six (6). LPA observed common areas to be very clean and tidy. LPA observed the floors to be in very good condition. No obstructions and or tripping hazards throughout the facility. Furniture in common area was observed to be in good repair. There are no issues with Fire Clearance.
Infection control
: Facility mitigation plan to make sure licensee was following current infection control recommendations. LPA obtain a copy and reviewed the infection control plan during this visit.
Surrounding Grounds
: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The facility does have a swimming pool, this is properly fenced and locked. The garage detached and is used for PPE storage and injection storage. Deficiency will be cited on LIC 809-D for keeping injections for residents who are no longer living in the facility.
Laundry service:
There is enough linen available to change weekly or more if need. Cleaning supplies are being stored in an unlock storage above the laundry. Deficiency will be cited on LIC 809-D.
Staff Files
: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Office space is located beside the living room by the entrance. Records were checked for expired or missing certificates and clearances: LPA conducted a file review of staff for criminal record clearances and current First Aid. The administrator file was reviewed for current first aid, fingerprint clearance, administrator certificate, and HIV/AIDS and TB training.
Continue to LIC 809-C
SUPERVISORS NAME
:
Nichelle Gillyard
LICENSING EVALUATOR NAME
:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE
:
DATE:
09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/17/2024
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
WOODLAND HILLS S.RO
,
21731 VENTURA BLVD., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
G & A CARE
FACILITY NUMBER:
197609731
VISIT DATE:
09/17/2024
NARRATIVE
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Medications
are in a centrally stored and locked place, including over-the-counter medicines; medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the clients’ doctor. LPA found medications that are prep for the day in a cup are accessible to residents in the kitchen 2nd drawer across the pantry. Deficiency will be cited on LIC 809-D. Proper medication dispensing instruction are followed and checked for contamination. First-aid has all proper items and is current.
Resident records
were reviewed for and legibility: LPA reviewed client’s files for current appraisal. Planned activities are offered.
Facility is not within CA code of Regulations Title 22 or Health and Safety Code. Citation has been issued on LIC 809-D. Exit interview conducted, copy of report has been issued and discussed.
SUPERVISORS NAME
:
Nichelle Gillyard
LICENSING EVALUATOR NAME
:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE
:
DATE:
09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/17/2024
LIC809
(FAS) - (06/04)
Page:
3
of
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Document Has Been Signed on
09/23/2024 11:42 AM
- It Cannot Be Edited
Created By:
Leslie Ngo-Castaneda
On
09/17/2024
at
02:31 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:
G & A CARE
FACILITY NUMBER:
197609731
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/17/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(a)
Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in no staff was observed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
09/18/2024
Plan of Correction
1
2
3
4
Licensee needs to have a staff when they licensee leaves the facility.
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:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE:
09/17/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/17/2024
LIC809
(FAS) - (06/04)
Page:
4
of
9
Document Has Been Signed on
09/23/2024 11:42 AM
- It Cannot Be Edited
Created By:
Leslie Ngo-Castaneda
On
09/17/2024
at
02:31 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:
G & A CARE
FACILITY NUMBER:
197609731
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/17/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(1)(C)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (C) Because of potential dangers related to the medication itself, or due to physical arrangements in the facility and the condition or the habits of other persons in the facility, the medications are determined by either a physician, the administrator, or Department to be a safety hazard to others.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on bservation, the licensee did not comply with the section cited above in 2 out of 2 prep-medications were accessible in the kitchen drawer; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
09/18/2024
Plan of Correction
1
2
3
4
Licensee needs to ensure that medications are not accessible and needs to be kept locked.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on bservation, the licensee did not comply with the section cited above in 2 out of 2 prep-medications were accessible in the kitchen drawer; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
09/18/2024
Plan of Correction
1
2
3
4
Licensee needs to ensure that medications are not accessible and needs to be kept locked.
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:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE:
09/17/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/17/2024
LIC809
(FAS) - (06/04)
Page:
5
of
9
Document Has Been Signed on
09/23/2024 11:42 AM
- It Cannot Be Edited
Created By:
Leslie Ngo-Castaneda
On
09/17/2024
at
02:45 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:
G & A CARE
FACILITY NUMBER:
197609731
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/17/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients
shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 1 out of 1 storage cabinet were unlock in the laundry room which poses an immediate health, safety or personal rights risk to persons in care..
POC Due Date:
09/18/2024
Plan of Correction
1
2
3
4
Licensee needs to ensure that chemicals and cleaning supplies needs to be kept locked at all times.
Type A
Section Cited
CCR
87465(i)
This requirement is not met as evidenced by: Incidental Medical and Dental Care
Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident.
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 3 out of 3 insulin injections were seen kept for residents who no longer resides at the facility; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/01/2024
Plan of Correction
1
2
3
4
Licensee needs to dispose all of the medication for residents who are no longer residing in the facility.
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:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE:
09/17/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/17/2024
LIC809
(FAS) - (06/04)
Page:
6
of
9
Document Has Been Signed on
09/23/2024 11:42 AM
- It Cannot Be Edited
Created By:
Leslie Ngo-Castaneda
On
09/17/2024
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., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
G & A CARE
FACILITY NUMBER:
197609731
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/17/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs
and showers.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 1 out of 1 non-skid mat for resident
bathroom was not available, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/01/2024
Plan of Correction
1
2
3
4
Licensee needs to purchase a non-skid mat for resident bathroom.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE:
09/17/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/17/2024
LIC809
(FAS) - (06/04)
Page:
7
of
9
Document Has Been Signed on
09/23/2024 11:42 AM
- It Cannot Be Edited
Created By:
Leslie Ngo-Castaneda
On
09/17/2024
at
03:33 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:
G & A CARE
FACILITY NUMBER:
197609731
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/17/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87211(a)(1)(A)
a.Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility. This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in three (3) residents identified by left over medication to have been deceased. Administrator could not provide date of death and admitted to submitting death reports which posed a potential health, safety or personal rights risk to persons
POC Due Date:
10/01/2024
Plan of Correction
1
2
3
4
Administrator agreed to submit death reports for the three (3) residents and destroy left over medication of those three
residents. Administrator will submit death report via email to LPA by POC due date 10.1.2024
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:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE:
09/17/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/17/2024
LIC809
(FAS) - (06/04)
Page:
8
of
9
Document Has Been Signed on
09/23/2024 11:42 AM
- It Cannot Be Edited
Created By:
Leslie Ngo-Castaneda
On
09/23/2024
at
11:33 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:
G & A CARE
FACILITY NUMBER:
197609731
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/17/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87413(a)(1)
(1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the
assigned tasks.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in no staff was observed which poses an
immediate health, safety or personal rights risk to persons in care.
POC Due Date:
09/18/2024
Plan of Correction
1
2
3
4
Licensee needs to have a staff when they licensee leaves the facility.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE:
09/23/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/23/2024
LIC809
(FAS) - (06/04)
Page:
9
of
9