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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609791
Report Date: 05/20/2021
Date Signed: 05/20/2021 02:31:51 PM

Document Has Been Signed on 05/20/2021 02:31 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:ATWATER VILLAGE SOUTHFACILITY NUMBER:
197609791
ADMINISTRATOR:ESPIRITU, JOCELYNFACILITY TYPE:
740
ADDRESS:3454 PERLITA AVETELEPHONE:
(323) 665-6893
CITY:LOS ANGELESSTATE: CAZIP CODE:
90039
CAPACITY: 6CENSUS: 5DATE:
05/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Jocelyn Espiritu TIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Naira Margaryan arrived to the facility to conduct unannounced REQUIRED -1-YEAR INSPECTION.
LPA met two facility staff and they assisted LPA during this visit.
At 12:55pm, LPA Margaryan spoke with the Administrator over the phone and explained the purpose of this visit.
At 1:00pm, LPA Margaryan inspected entire facility inside and out.
LPA inspected the residents bedrooms, bathrooms, living room, dining area, kitchen and food supply. In addition, LPA observed and assessed all five (05) residents residing in the facility.
At the time of this visit the facility retained one hospice resident.
Upon inspection, LPA observed the bed located in the large storage room and was informed that the storage space is being used as a staff bedroom. Both staff members were staying at the facility and the second staff was sleeping on the sofa located in the office area adjacent to the kitchen.
Front yard and backyard was inspected and there clear from obstruction.
The facility mitigation plan and Emergency evacuation plan was discussed during this visit.
The Administrator was advised that no storage space or common area can be used as a sleeping quarter for the caregivers and if facility does not have designated room for the staff, than they should have awake night shift staff.
Under Title 22 Division 6, Chapter 8, following citation was issued and recorded on LIC809D.
No immediate health and safety hazard is noted during this visit.
Exit interview was conducted and a copy of report was issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Naira Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2021
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 05/20/2021 02:31 PM - It Cannot Be Edited


Created By: Naira Margaryan On 05/20/2021 at 01:59 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: ATWATER VILLAGE SOUTH
FACILITY NUMBER: 197609791

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
87307(a) Personal Accommodations and Services. A facility’s buildings and grounds shall have no other purpose than those related to the care, comfort and privacy of the residents, staff, and others who may reside in the facility.
This requirement is not met as evidenced by
Deficient Practice Statement
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Based on inspection, observation and interview, the licensee did not comply with the section cited above. The two live in staff are sleeping in the large storage room and on the sofa located in the common area. This poses an immediate health and safety and personal rights risk to residents in care:

POC Due Date: 05/21/2021
Plan of Correction
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The Administrator stated that the storage room will be cleaned and the bed will be removed immediately. After removing the furniture, the Administrator will take a picture of the empty storage room and sent a picture to the Licensing Office along with written statement that moving forward the building will be used as permitted and for the comfort and privacy of residents, and staff.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Naira Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2021


LIC809 (FAS) - (06/04)
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