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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 10:50:47 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 - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Clarita ZinkofskyTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Brian Balisi arrived unannounced to conduct a Case Management - Deficiencies visit at this facility. Upon arrival LPA met with Clarita and explained the reason for the visit. 
 
At approximately 9am, LPA conducted physical plant, interviewed residents and staff as well as reviewed facility documents.
 
Prior to visit , LPA printed out the facility personnel report summary from the Licensing Information System (LIS). Upon arrival, it was revealed that S1 has been working at the facility since it was licensed. Per record review, conducted by LPA on the Guardian website, S1 does have a criminal record clearance, but is not associated to this facility.
 
The Administrator stated that the facility will ensure that all staff will have a criminal record clearance and are associated to the facility prior to working at the facility.
 
Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to Lice 809-D). Civil penalties assessed in the amount of $500. Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted, appeal rights discussed 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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Document is an Amendment of Original Document on 09/13/2023 02:41 PM


Created By: Brian Balisi On 01/19/2023 at 10:15 AM
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: KAREN'S SENIORS CARE HOME, INC.
FACILITY NUMBER: 197609932

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/20/2023
Section Cited
CCR
87355(e)(2)

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All individuals subject to a criminal record... residing or volunteering in a licensed facility:
(2) Request a transfer of a criminal record clearance as specified in Section 87355 C …

This requirement is not met as evidenced by:
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Licensee agreed to submit a transfer of a criminal record clearance for all staff not associated to the facility by 01/19/2023. Licensee will submit proof of clearance to LPA via email by eod 01/19/2023.
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Based on record review and interview the licensee did not comply with the section cited by not transferring the criminal record clearance for S1 to this facility prior to employment which poses an immediate health, safety and 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:Desaree Perera
LICENSING EVALUATOR NAME:Brian Balisi
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023


LIC809 (FAS) - (06/04)
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