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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609932
Report Date: 05/09/2023
Date Signed: 05/09/2023 01:34:47 PM

Document Has Been Signed on 05/09/2023 01:34 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:
05/09/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:18 AM
MET WITH:Clarita ZinkofskyTIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Kelly Dulek initiated a Case Management – Deficiencies visit to address deficiencies observed during a complaint investigation. LPA met with Facility Designee Clarita Zinkofsky. Entrance interview conducted.

During a previous investigation at the facility, interviews revealed that multiple fall incidents occurred involving Resident #1 (R1.) Interview revealed that R1 fell around September or October 2020 resulting in laceration to R1’s eye and additional medical attention, on 02/16/2021 resulting in bruising and again on 02/20/2021 resulting in bruising and additional medical attention. LPA reviewed documents received in the Woodland Hills Regional Office and confirmed that no incidents were reported involving R1 in September or October 2020 and no incident report was received for the 02/16/2021 incident either. It was also revealed that although R1 fell at 04:00AM on 02/20/2021, facility designee did not arrive at the facility to assess R1 until around 01:00PM and facility staff called 9-1-1 around 02:00PM. R1 was then transported to the hospital to receive further medical attention due to the fall. Additionally, interviews revealed that both Administrator and facility designee refused to readmit R1 to the facility following R1’s hospitalization. Facility designee indicated to LPA that the family refused to relocate R1 when previously discussed, and that sending R1 to the hospital was the “chance to get [R1] out of here.”

The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Civil penalty issued in the amount of $250. Facility Designee was informed that failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 05/09/2023 01:34 PM - It Cannot Be Edited


Created By: Kelly Dulek On 05/09/2023 at 11:43 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
, 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: 05/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/10/2023
Section Cited
CCR
87465(a)(1)

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall...(1) The licensee shall arrange, or assist in arranging, for medical...conditions and needs of residents.
This requirement is not met as evidenced by:
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Facility designee will provide LPA with the document all facility staff are trained on and have signed off on with the new facility procedure for calling 9-1-1 immediately by POC due date.
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Based on interviews, the licensee did not comply with the section cited above as facility staff did not take action to have R1 transported to a medical facility for 10 hours after R1 fell and sustained a head injury, which posed an immediate health and safety risk to residents in care. Civil penalty issued.
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Type A
05/17/2023
Section Cited
CCR87468.2(a)(20)

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities(a)(20) To be protected from involuntary transfers, discharges, and evictions...shall comply with all eviction and relocation protections for residents...not by the resident.
This requirement is not met as evidenced by:
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Facility designee will provide to LPA by the POC due date a plan for eviction notification to implement for all future evictions.
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Based on interview, the licensee did not comply with the above cited section, as R1 was sent to the hospital and facility designee refused to readmit R1, which posed an immediate 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:Kristin Heffernan
LICENSING EVALUATOR NAME:Kelly Dulek
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/09/2023 01:34 PM - It Cannot Be Edited


Created By: Kelly Dulek On 05/09/2023 at 11:53 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
, 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: 05/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/23/2023
Section Cited
CCR
87211(a)(1)(D)

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87211 Reporting Requirements (a)(1)(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
This requirement is not met as evidenced by:
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Facility designee agreed to provide to LPA a copy of the facility's current plan for falls and unusual incident procedure by POC due date.
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Based on record review, the licensee did not comply with the above cited section as an incident involving R1 that occurred at the facility around September 2020 and an incident on 02/16/2021 were not reported to CCLD, which posed a potential health and safety 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:Kristin Heffernan
LICENSING EVALUATOR NAME:Kelly Dulek
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023


LIC809 (FAS) - (06/04)
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