<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609950
Report Date: 02/26/2024
Date Signed: 02/26/2024 04:57:01 PM

Document Has Been Signed on 02/26/2024 04:57 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
WOODLAND HILLS S.RO, 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:
02/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Sofya Khechikyan, AdministratorTIME COMPLETED:
05:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At 9:45 AM Licensing Program Analyst (LPA), Huma Rahimi, conducted an unannounced annual inspection at the facility mentioned above. LPA met with the staff Anahit Zohrabyan and later Administrator Sofya Khechikyan arrived and explained the reason for the visit. Physical tour was conducted with the Administrator and LPA observed the following:

Kitchen: At 10:21 AM LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. LPA observed multiple scissors in two different drawers of the kitchen unlocked and available to residents in care. Toxin (comet) under the sink cabinet were observed unlocked and accessible to residents in care.

Medications: At 10:26 AM LPA observed medications are centrally stored and locked closet in a hallway amongst bedrooms # one (1), and # two (2), and three (3). The locked closet also contained residents and staff files. Additionally, LPA observed over the counter stomach relief medication unlocked and accessible to residents in the kitchen cabinet. Injectable diabetes medications for a resident were observed unlocked in the refrigerator in the kitchen.

Bedrooms: The facility has six (6) bedrooms in total. Bedroom # one (1), and bedroom # five (5) are shared. In bedroom # five (5), a relative of the administrator lives who is fingerprint cleared. Bedrooms # two (2), three (3), and four (4) are private. All bedrooms were clean and odorless. Furniture was in good repair. Bedroom #3 was designated for a bedridden resident, and the emergency exit was free from obstruction. One of the bedrooms located near the kitchen is designated for staff and LPA observed free of hazard and obstruction. LPA also observed a scissor in a resident bedroom # four (4). A knife was accessible in a shared bedroom # five (5).

Continue on LIC 809C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE: DATE: 02/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/26/2024
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 4
Document Has Been Signed on 02/26/2024 04:57 PM - It Cannot Be Edited


Created By: Huma Rahimi On 02/26/2024 at 03:14 PM
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: 02/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in two out of two toxins (Comet & Laundry detergent) accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/01/2024
Plan of Correction
1
2
3
4
Toxins were immediately locked away. Administrator agreed to train the staff and submit the proof to LPA by due date.
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in one out of one knife and three out of three scissors in the kitchen as well as in residents rooms which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/01/2024
Plan of Correction
1
2
3
4
Administrator immediately removed and locked away the sharps. Administrator also agreed to provide training to their staff and provide LPA with a proof by the due date.
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Huma Rahimi
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PRIME RESIDENTIAL SENIOR CARE
FACILITY NUMBER: 197609950
VISIT DATE: 02/26/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Bathrooms: The facility had 3 bathrooms. Bathrooms #1 and #2 were located at the front. They contained paper towels, liquid soap, and trash cans with tight fitting lids. Bathroom #3 was connected to Bedroom #4. It contained liquid soap, paper towels, a lidless trash can, and a shower with grab bars and a non-skid mat. Hot water temperature measured at 119.3°F.

Common Areas: The facility maintains a comfortable temperature at 73°F. The living room and dining area appeared clean and were properly furnished. The living room has a television, comfortable furniture. No obstructions and or tripping hazards throughout the facility.

Garage: LPA entered a locked garage and saw more cleaning supplies, hazardous liquids, detergents, extra PPE, and a refrigerator for extra food for staff.

Laundry: The laundry is located between the kitchen and garage. LPA observed an unlocked laundry detergent accessible to residents in the laundry room. Staff admitted to LPA that they forgot to lock it away after using it this morning.

Outside and Back Yard: LPA toured the two side paths and back yard. Both emergency exit gates were unlocked, and paths were free from debris. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. The back yard contained a gardening space.

Smoke detectors/carbon monoxide. Smoke detectors were located throughout the facility, and at 10: 44 AM, they were tested and observed to be operational. Carbon monoxide was living room and was also tested and observed to be operational. LPA heard functioning auditory alarms on all exit doors.

Between 12:20 AM to 3:30 AM, LPA reviewed records of six (6) residents and two (2) staff. Residents and staff records appeared to be complete and updated.

Deficiencies cited during today’s visit. Appeal rights issued and given.

Exit interview conducted and copy of this report signed and delivered.

Administrative: LPA collected Certificate of Liability Insurance, and LIC500.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/26/2024 04:57 PM - It Cannot Be Edited


Created By: Huma Rahimi On 02/26/2024 at 03:48 PM
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: 02/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (f) The following shall be stored inaccessible to residents with dementia: (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in two out of two medication storage, medication for diabetes unlocked in the fridge &over the counter medication of stomach relife unlocked and accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/01/2024
Plan of Correction
1
2
3
4
Administrator locked medication and removed from the fridge and put it in the fridge in garage for now. Administrator will buy a separate small fridge for diabetes medication and submit the receipt to LPA including the training for staff.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Huma Rahimi
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2024


LIC809 (FAS) - (06/04)
Page: 4 of 4