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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609766
Report Date: 04/07/2022
Date Signed: 04/07/2022 06:36:16 PM

Document Has Been Signed on 04/07/2022 06:36 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:HORIZON ASSISTED LIVING FACILITYFACILITY NUMBER:
197609766
ADMINISTRATOR:SONA GEVORKYANFACILITY TYPE:
740
ADDRESS:9708 VALJEAN AVETELEPHONE:
(310) 720-4551
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 6CENSUS: 4DATE:
04/07/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
06:01 PM
MET WITH:Svetlana PetrosyanTIME COMPLETED:
06:45 PM
NARRATIVE
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An unannounced Case Management Deficiencies visit in conjunction with a subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. The purpose of this visit is to address deficiency identified during today's visit that is not related to the complaint control 31-AS-20210326092829. Upon arrival, the LPA met with staff .Svetlana Petrosyan and Volunteer Anush Danelyan. Ms. Petrosyan contacted administrator Sona Gevorkyan via telephone. LPA spoke with Ms. Gevorkyan who stated she is far from facility and would not be able to come for the visit. Ms. Gevorkyan designated Ms. Petrosyan to sign for the report.


While speaking with staff LPA requested the names for the 2 staff observed when entering the facility. Ms. Petrosyan provided her name and last name. LPA then asked for the name of the other individual Ms. Petrosyan stated that the person is a volunteer. The volunteer left the facility shortly after the LPA's arrival. While reviewing the complaint report prior to final printing Ms. Petrosyan was speaking on the phone with the administrator in Armenian. They were discussing the volunteer and status of her criminal record clearance. After the phone conversation ended LPA asked Ms. Petrosyan about the volunteer. At that time Ms. Petrosyan informed the LPA that Ms. Danelyan is not a volunteer, but is her personal assistant and does not provide assistance with residents. A discussion was held why her personal assistant is walking around the facility, near resident rooms. Approximately 6:10 pm LPA conducted interviews with 3 of the facility residents. When interviewed all residents confirmed that the volunteer has been working at the facility and providing them care for approximately a month. Residents interviewed also confirmed that Ms. Petrosyan and Ms. Danielyan started working at the facility "around the same time"

Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited: (Refer to LIC 809-D). Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2022
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 04/07/2022 06:36 PM - It Cannot Be Edited


Created By: Yelena Avetisyan On 04/07/2022 at 06:19 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: HORIZON ASSISTED LIVING FACILITY
FACILITY NUMBER: 197609766

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/08/2022
Section Cited
CCR
87355(e)(1)

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Criminal Record Clearance (e) 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 .
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Licensee/Administrator will ensure the staff member receives criminal record clearance prior to returning to the facility. Licensee/administrator will submit verification of Live scan and photo ID of volunteer who left the facility.
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This requirement is not met as evidenced by
Based on observation and interview the licensee/administrator did not comply with the section cited by allowing S2 to work at the facility prior to obtaining criminal record clearance which poses an immediate health and safety risk to residents in care.
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This is a zero tolerance violation therefore a civil penalty in the amount of $500.00 has been issued. Civil penalties will continue to accrue until plan of correction is submitted.
Type A
04/09/2022
Section Cited
CCR87207

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No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.

This Requirement was not met as evidenced by:
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Licensee/Administrator designee will submit a written explanation to the department regarding their actions.
Licensee/Administrator an all staff will also attend vendorized training for the following title 22 regulations. 87408: Denial or Revocation of a Certificate, 87777: Exclusions, Personal Rights
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Based on the information obtained by LPA during the visit the licensee/administrator and staff did not comply with he cited section by providing false/misleading statements to LPA regarding Staff/volunteer which posed an immediate personal rights violation to residents in care.
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 1) Verification of the scheduled training with the credentials of the trainer will need to be emailed to the LPA by 4/9/2022.

2) Verification of completed training will need to be submitted to the LPA by 4/19/2022.
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:Eva Miller
LICENSING EVALUATOR NAME:Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2022


LIC809 (FAS) - (06/04)
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