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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609889
Report Date: 04/21/2021
Date Signed: 04/21/2021 05:14:37 PM

Document Has Been Signed on 04/21/2021 05:14 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:PEARL OF WEST HILLS, INCFACILITY NUMBER:
197609889
ADMINISTRATOR:IRINA, KARBACHINSKIYFACILITY TYPE:
740
ADDRESS:23427 VICTORY BLVDTELEPHONE:
(818) 854-6306
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY: 6CENSUS: 2DATE:
04/21/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Irina KarbachinskiyTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yelena Avetisyan conducted an unannounced Virtual Case Management Deficiencies visit due to deficiencies observed during the investigation of complaint control 31-AS-20210416135138 on 4/20/2021.

Upon entrance to the facility on 4/20/2021 LPA observed a key lock inside the facility entrance door. At 2:40 pm LPA took a photo of the door and spoke with the administrator who stated that she has to lock the door to prevent Resident 1 (R1) from leaving the facility. At 3:18 pm LPA also observed the back gate of the property also with a key lock installed from inside the backyard. LPA informed administrator that the locks needed to be removed/replaced immediately but no later than today 4/21/2021.

On 4/20/2021 from 2:15 pm to 2:30 LPA conducted a tour of the facility with the administrator. From 2:30 to 4:30 LPA conducted interview with administrator and reviewed files for Resident 1 (R1) and Resident 2 (R2). While reviewing the residents files LPA observed that files for both residents are incomplete.

Resident files were missing the following documents:

  • Physicians report with TB test, (R1)
  • Current Centrally stored medication and destruction log. (R1 and R2)
  • Admission agreement, (R1 and R2)
  • Pre-Admission appraisal(R1)
  • functional Capabilities (R1)
  • Identifications and emergency information sheet (R1 and R2)
  • Licensee did not have hospice care plan (R1)
  • Order for full rails. (R1)
  • No PRN administration logs used for R1 and R2
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PEARL OF WEST HILLS, INC
FACILITY NUMBER: 197609889
VISIT DATE: 04/21/2021
NARRATIVE
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Today 4/21/2021 at 3:00 pm LPA called the facility to speak with administrator. Phone was answered by an unknown individual who gave the phone to administrator. LPA asked administrator about the individual who answered the phone. LPA was informed that the person was a volunteer, who the administrator was trying out to see if she can hire.

At 3:05 LPA called administrator via FaceTime. When administrator answered the phone the "volunteer" was washing dishes. LPA informed administrator that all staff are required to have criminal record clearance and the clearance has to be transferred to the facility prior to volunteering or working at the facility.
LPA asked administrator to show her the front doors. Administrator informed LPA that the locks have not been removed and that a handyman would be coming 10:00 am tomorrow. At 3:52 pm LPA received a call from the administrator who stated that she scheduled a handyman to replace the locks 6:00 pm today.

Exit interview was conducted via telephone and copy of report with citations were emailed to administrator for signature. .
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2021
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Document Has Been Signed on 04/21/2021 05:10 PM - It Cannot Be Edited


Created By: Yelena Avetisyan On 04/21/2021 at 04:02 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: PEARL OF WEST HILLS, INC
FACILITY NUMBER: 197609889

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/22/2021
Section Cited
CCR
87705(l)(5)

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The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates:
(2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates. This requirement is not being met as evidenced by
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The administrator agrees to change the locks on the front and back doors of the facility so that the dead bolt can be opened without a key from the inside. A photo will be sent to the LPA as a POC by the POC date of 4/22/21
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LPA observation and administrator confirmation while conducting a tour of the facility and interview conducted with administrator on 4/20/21 which revealed that the front door and back gate door are locked and can only be opened with a key which poses an immediate health and safety and personal rights violation to residents in care.
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Type A
04/22/2021
Section Cited
CCR87468.1(a)(c)

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Personal Rights of Residents
....to leave or depart the facility at any time....

This requirement was not met as evidenced by:
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The administrator agrees to change the locks on the front and back doors of the facility so that the dead bolt can be opened without a key from the inside. A photo will be sent to the LPA as a POC by the POC date of 4/22/21
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Based on observations made and interviews with licensee/administrator which revealed that lhe licensee locks with a key lock inside the facility to prevent resident from wondering out which poses an immediate health and safety and personal rights violation to residents in care.
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Administrator will also reviewed all regulations related to residents personal rights and dementia. Once completed administrator will submit a written statement indicating the regulations that they reviewed and understood.
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:Cassandra Harris
LICENSING EVALUATOR NAME:Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2021


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Document Has Been Signed on 04/21/2021 05:10 PM - It Cannot Be Edited


Created By: Yelena Avetisyan On 04/21/2021 at 04:18 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: PEARL OF WEST HILLS, INC
FACILITY NUMBER: 197609889

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/21/2021
Section Cited
CCR
87355(e)(2)

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(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: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
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Licensee will submit the paperwork to transfer the criminal record clearance for staff or send a written statement that staff/volunteer will not longer be present or working at the facility.
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Based on record review the licensee did not comply with the section cited above by not transferring criminal record clearance for staff 1 (S1) which poses an immediate health, safety or personal rights risk to persons in care.
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This is a Zero Tolerance violation therefore civil penalties have been issued in the amount of $500 dollars.
Type B
04/27/2021
Section Cited
CCR87458(b)(1)

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87458(b)(1) Medical Assessment. The medical assessment, shall include: A physical exam of the resident containing a primary and secondary diagnosis, if any, results of a test for tuberculosis and any medical conditions which would preclude care of the person in an RCFE
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Administrator stated she will obtain a Medical Assessment with TB test for R1 and submit copy of the department as POC.
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This requirement is not met as evidenced by:
Based on record review conducted on 4/21/2021, licensee failed to obtain medical assessment and TB test result for 1 out 2 residents (R1) which poses a potential health risk to resident 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:Cassandra Harris
LICENSING EVALUATOR NAME:Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2021


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Document Has Been Signed on 04/21/2021 05:10 PM - It Cannot Be Edited


Created By: Yelena Avetisyan On 04/21/2021 at 04:26 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: PEARL OF WEST HILLS, INC
FACILITY NUMBER: 197609889

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/21/2021
Section Cited
CCR
87608(a)(5)(B)

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(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

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Licensee/Administrator will review the regulation., contact the hospice agency and obtained a current hospice care plan which will indicate the need for the full rail. Copy of the hospice care plans will be submitted as POC.
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Based on 4/20/2021 observation and interview, the licensee did not comply with the section cited above by utilizing full bed rails for 1 out of 2 residents, (R1) who is on hospice however the licensee does not have a hospice care plan that identifies the need for the full rails which poses an immediate health, safety & personal rights risk to R1.
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Type B
04/23/2021
Section Cited
CCR87633(b)

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(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:

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Licensee/Administrator will review the regulation and contact the hospice agency to request a complete hospice care plan, administrator will ensue the care plan includes all information as required by the regulation 87633. Copies of the hospice care plans will need to be submitted as POC.
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Based on 4/20/2021 record review, the licensee did not comply with the section cited above by not maintaining a hospice care plan for 1 out of 1 resident who is currently receiving hospice services which poses a potential health, safety or personal rights risk to person 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:Cassandra Harris
LICENSING EVALUATOR NAME:Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2021


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Document Has Been Signed on 04/21/2021 05:10 PM - It Cannot Be Edited


Created By: Yelena Avetisyan On 04/21/2021 at 04:31 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: PEARL OF WEST HILLS, INC
FACILITY NUMBER: 197609889

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/23/2021
Section Cited
CCR
87465(h)(6)

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87465(h)(6) Incidental Medical and Dental Care. The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained...This requirement is not met as evidenced by:
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Administrator will complete centrally stored medication and destruction records for both residents. Copies of the records will need to be submitted as POC
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Based on observation, record review and interviews, licensee failed to have a complete centrally stored medication records for 2 out of 2 resident (R1, R2, ) which poses a potential health and safety risk to residents in care.
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Type B
04/23/2021
Section Cited
CCR87465(C3)(D3)

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(3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.
This requirement is not met as evidenced by:
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Administrator will create PRN administration log to be utilized at the facility. A copy of the log with a written statement indicating that PRN logs will be used as necessary for all residents will be submitted as POC.
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Based on records reviewed and interview conducted on 4/21/2021 which revealed that licensee/administrator does not use PRN administration log which poses a potential health and safety and 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:Cassandra Harris
LICENSING EVALUATOR NAME:Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2021


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Document Has Been Signed on 04/21/2021 05:10 PM - It Cannot Be Edited


Created By: Yelena Avetisyan On 04/21/2021 at 04:46 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: PEARL OF WEST HILLS, INC
FACILITY NUMBER: 197609889

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/21/2021
Section Cited
CCR
87506(b)

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(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
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Licensee/Administrator will review files for all residents and ensure all files have the required documents.
Licensee/Administrator will submit a written statement confirming that all residents files have been completed as required.
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Based on 4/20/2020 record review, the licensee did not comply with the section cited above by not having a complete file for 2 out of 2 residents which poses a potential health, safety or personal rights risk to persons 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:Cassandra Harris
LICENSING EVALUATOR NAME:Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2021


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