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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609932
Report Date: 01/19/2023
Date Signed: 01/19/2023 10:50:26 AM

Document Has Been Signed on 01/19/2023 10:50 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:KAREN'S SENIORS CARE HOME, INC.FACILITY NUMBER:
197609932
ADMINISTRATOR:ZINKOFSKY, BRANDONFACILITY TYPE:
740
ADDRESS:17610 HAYNES STREETTELEPHONE:
(818) 205-3820
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY: 6CENSUS: 5DATE:
01/19/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Clarita Zonkofsky TIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced Case Management - Incident visit for an  incident reports received at the Regional Office on 01/17/2023. Upon arrival LPA met with Administrator Clarita Zinkofsky and explained the reason for the visit.

The incident report was authored by Administrator who  indicated that on 01/12/2023,  the private caregiver of Resident 1 (R1) alleged that Staff 1 (S1) and Staff 2 (S2) physically abused R1 while in care. No  date and time of abuse was indicated. According to incident report, the  Administrator contacted the responsible party of R1 and the  Hospice nurse visited the facility  to evaluate R1. No potential or  immediate concerns were found by hospice at that time.

At approximately 9am, LPA interviewed staff, (3) residents and reviewed and obtained pertinent documents relevant to the incident. Further investigation  is required at this time.

Exit interview conducted and report issued to Administrator.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2023
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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