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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609932
Report Date: 02/02/2023
Date Signed: 02/02/2023 03:57:44 PM

Document Has Been Signed on 02/02/2023 03:57 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. #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: 6DATE:
02/02/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Brandon Zinkofsky - AdministratorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent unannounced Case Management - Incident visit to further investigate the incident report received at the Regional Office 01/17/2023. Information on the incident can be found on the initial Case Management - Incident report, which  occurred on01/19/2023. Upon arrival LPA met with Administrator  Brandon Zinkofsky and explained the reason for the visit.

On 01/19/2023, LPA conducted initial Case Management - Incident visit and toured facility with Administrator, interviewed staff and residents and reviewed and obtained copies of pertinent documents relevant to the investigation.
On 01/30/2023, LPA interviewed family member of Resident 1 (R1).

Today LPA conducted physical plant, interviewed Staff 3 (S3), R1,  as well as the  Private Caregiver of R1 and the Hospice nurse of R1.
LPA's interviews throughout the investigation  with (3) residents, (5) staff, along with family member, the private care giver and hospice nurse revealed there was not sufficient evidence to prove physical abuse occurred.  All parties interviewed also stated they have never observed any staff physically abuse R1 or other residents in care. The family member, private caregiver and hospice nurse continued to state they each had no immediate or potential concerns of any staff physically abusing R1 or other residents in care at this time.
LPA records review of internal investigation conducted by facility revealed there was not sufficient evidence to prove physical abuse had occurred.

No immediate health and safety concerns were observed during the visit and no deficiencies cited at this time.

Exit interview conducted and report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2023
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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