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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609889
Report Date: 11/17/2021
Date Signed: 11/17/2021 05:08:26 PM

Document Has Been Signed on 11/17/2021 05:08 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: 6DATE:
11/17/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Irina KarbachinskiyTIME COMPLETED:
05:10 PM
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An unannounced Plan of Correction (POC) visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. The purpose of this visit is to follow up on the Case Management Deficiencies visit and a subsequent complaint visit Complaint Control # 31-AS-20210416135138 which were conducted on 11/5/2021. Upon arrival LPA met with staff Olga Nikolaevna, Licensee/administrator Irina Karbachinskiy arrived to the facility approximately 3:20 pm.

During the 11/5/2021 Case Management Deficiencies visit the licensee was issued a citation for the deficiency of not having a certified administrator working at the facility. The plan of correction due date for the citation was 11/8/2021. As of today's visit a plan of correction has not been submitted to the Department. The licensee was also cited for the same deficiency on 4/20/2021 and did not submit the plan of correction.

For the subsequent complaint visit the licensee was cited for:

87465 (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. The plan of correction was for the licensee to schedule vendorized medication training for all staff and submit a written statement notifying the department what steps will be taken to prevent the reoccurrence of the cited deficiency on or before 11/8/2021.

87465 (C3)(D3) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date & time the PRN medication was taken, the dosage taken, & the resident's response.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2021
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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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: 11/17/2021
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The plan of correction was for the licensee to schedule vendorized medication training by 11/8/2021

87465 (c)(2) (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff shall be permitted to assist the resident with self-administration, provided the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. The plan of correction was for the licensee to schedule vendorized medication training for all staff and submit a written statement notifying the department what steps will be taken to prevent the reoccurrence of the cited deficiency on or before 11/8/2021.

As of today's visit Licensee has failed to submit the plan of corrections for all deficiencies documented in this report, which were cited on 11/5/2021. The licensing reports issued on 11/5/2021 gave notice that failure to correct the violations within a specified length of time would result in civil penalties. Because the licensee failed to make the corrections by the specified dates a civil penalty in the amount of $100 dollars per violation per day will be assessed until the plan of correction is submitted.

Exit interview conducted, copy of report, citations and civil penalties emailed to the administrator.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
LIC809 (FAS) - (06/04)
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