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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609950
Report Date: 07/20/2023
Date Signed: 07/20/2023 12:40:59 PM

Document Has Been Signed on 07/20/2023 12:40 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:PRIME RESIDENTIAL SENIOR CAREFACILITY NUMBER:
197609950
ADMINISTRATOR:KHECHIKYAN, SOFYAFACILITY TYPE:
740
ADDRESS:19418 LANARK STREETTELEPHONE:
(818) 626-8553
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 6CENSUS: 6DATE:
07/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:24 AM
MET WITH:Sofya KhechikyanTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Evelin Rios and Michael Cava conducted an unannounced case management visit - deficiencies visit in conjunction to complaint control number 31-AS-20230623141817. The purpose of this visit was explained to administrator Sofya Kechikyan. During complaint investigation conducted on 06/30/2023 LPA observed the following: a room converted from the living room utilized for an additional dwelling. Review of facility sketch does not indicate that their is a room created in the living room area for an additional occupant. Interview with administrator revealed occupant is a relative and is living in the created bedroom. Furthermore administrator states, this occupant is not receiving elements of care and supervision from facility staff. LPA review of records revealed that the occupant has fingerprint clearance.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2023
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 Has Been Signed on 07/20/2023 12:40 PM - It Cannot Be Edited


Created By: Evelin Rios On 07/20/2023 at 11:58 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PRIME RESIDENTIAL SENIOR CARE
FACILITY NUMBER: 197609950

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/28/2023
Section Cited
CCR
87208(a)(7)(A)

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...Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:(7) Sketches, showing dimensions, of the following: Building(s) to be occupied, including a floor plan that describes the capacities of the buildings... This requirement is not met as evidenced by:
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Licensee aggress to submit and LIC200 and updated facility sketch indicating a change in facility floor plan by or before POC due date.
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Based on LPA's observation on 06/30/2023 there was an additional room created by the Licensee which was not reflected on the facility sketch during the application process, which posed a potential health and safety issue for 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:Eva Miller
LICENSING EVALUATOR NAME:Evelin Rios
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023


LIC809 (FAS) - (06/04)
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