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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609995
Report Date: 04/27/2021
Date Signed: 04/27/2021 01:11:19 PM

Document Has Been Signed on 04/27/2021 01:11 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:HEART OF HOME SENIOR LIVINGFACILITY NUMBER:
197609995
ADMINISTRATOR:MOVSESIAN, KAJOFACILITY TYPE:
740
ADDRESS:6425 NAGLE AVETELEPHONE:
(747) 247-2365
CITY:VAN NUYSSTATE: CAZIP CODE:
91401
CAPACITY: 6CENSUS: 5DATE:
04/27/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Kajo MovsesianTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Eva Miller conducted a complaint investigation visit (Complaint # 29-AS-20210426111448). During the visit LPA observed deficiencies not included in the complaint allegations. A simultaneous Case Management Visit was conducted. LPA met with Facility Administrator Kajo Movsesian.

Upon arrival at 10:00am, LPA observed Direct Care Staff Anush Amivkahnyan (S-1) place paper medication cups with medications on the dining table next to food items intended for Residents in care who were not present in the room. The medication was left accessible to anyone in the room.

During the interview with the Administrator at 10:30am, it was determined that on or about 11/1/20 Resident #1 (R-1) required emergency medical attention and 911 was called. R-1 was transported via ambulance to an acute care hospital and subsequently admitted. No Incident Report was submitted to Community Care Licensing (CCL). The Administrator confirmed that this requirement was not met. During the same interview it was determined that on or about 11/7/20, R-1 passed away while in hospital. No Death Report was submitted to CCL. The Administrator confirmed that this requirement was not met.

Citations issued, appeal rights provided, exit interview conducted and copy of licensing report provided.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Eva Miller
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2021
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 2
Document Has Been Signed on 04/27/2021 01:11 PM - It Cannot Be Edited


Created By: Eva Miller On 04/27/2021 at 12:32 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HEART OF HOME SENIOR LIVING
FACILITY NUMBER: 197609995

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/27/2021
Section Cited
CCR
87465(h)(2)

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Incidental Medical and Dental Care. Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by:
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Medication was secured during the visit. Administrator agreed to provided additional in-service training for Staff #1 specific to assisting residents with self administration of medication. A copy of an attendance sheet with date, time and staff signature will be provided to CCL within 24 hours.
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Based on the observation of LPA Miller, Staff #1 (S-1) left medication unattended, unsecured and accessible to anyone in the room. This deficiency resulted in an immediate risk to the health & safety of Residents in care.
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Type B
04/30/2021
Section Cited
CCR87211(a)

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Reporting Requirements: Each licensee shall furnish to the licensing agency such reports as the Department may require. The requirement was not met as evidenced by:
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Administrator agrees to complete and submit an Incident Report and a Death Report for the hospitalization and death of R-1 in November of 2020.
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Based on confirmation from the Administrator required reporting of the hospitalization and subsequent death of R-1 was not submitted to CCL. This deficiency resulted in a potential risk to the operation of the facility.
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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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Eva Miller
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2021


LIC809 (FAS) - (06/04)
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