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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609995
Report Date: 07/28/2023
Date Signed: 07/28/2023 01:00:27 PM

Document Has Been Signed on 07/28/2023 01:00 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: 4DATE:
07/28/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Kajo Movsesian, AdministratorTIME COMPLETED:
01:10 PM
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At 9:35 a.m., Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Annual Continuation at the facility today continuing the inspection that began on 06/27/2023. At 10:00 a.m., the Administrator arrived at the facility.
RECORD REVIEW: Between 10:10 a.m. and 11:20 a.m., the LPA conducted a file review for all residents and staff regularly scheduled and observed the following: Staff have current first aid and training documentation showing required training completed. All personnel/ staff files were in order. Resident records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. The following was noted: one (1) out of four (4) resident files reviewed did not contain a current reappraisal. The Administrator did not reassess and update the reappraisal for Resident #1’s (R1) in the past 12 months (last reappraisal dated 06/26/22). Discussion held with Administrator and the Administrator stated that R1’s reappraisal will be updated. Remaining files reviewed were observed to be in compliance. MEDICATIONS: Between 11:35 a.m. and 12:08 p.m., the LPA conducted a review of medication and medication documentation with the Administrator for four (4) out of four (4) residents and observed the following: R1’s Carvedilol 6.25 mg (take 1 tablet twice a day) had 12 tablets remaining, however the medication was started on 06/28/2023 and the quantity was 60. Resident #2’s (R2’s) Levothyroxine 125 MCG Tablet (take 1 tablet once a day) had 3 tablets remaining, the medication was started on 06/27/2023 and the quantity was 30. Resident #3’s (R3’s) SM Melatonin 5MG (take 1 tablet once a day) had 2 tablets remaining, the medication was started on 06/27/2023 and the quantity was 30. The LPA had a discussion with the Administrator regarding the inconsistencies of R1, R2, and R3s medication and the Administrator stated that facility staff, including himself will be trained on medications. At 12:10 p.m., the LPA toured the physical plant areas inside and outside, with Administrator to ensure there are no health and safety hazards.

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8 and California Health and Safety Code the following deficiency was cited (refer to LIC 809-D) Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2023
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 07/28/2023 01:00 PM - It Cannot Be Edited


Created By: Emily Peraldi On 07/28/2023 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: 07/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as 3 of 4 resident medications reviewed contained inconsistencies with their medication amounts remaining and amounts documented as administered on the centrally stored which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/04/2023
Plan of Correction
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Administrator agreed to do a complete medication audit for the facility and training for all medication staff and submit documentation to CCL by POC due date. The Administrator within 24 hours will provide the LPA of the training dates.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Emily Peraldi
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023


LIC809 (FAS) - (06/04)
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