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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610054
Report Date: 10/24/2024
Date Signed: 10/24/2024 02:31:39 PM

Document Has Been Signed on 10/24/2024 02:31 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:LEO'S ASSISTED LIVING IIFACILITY NUMBER:
197610054
ADMINISTRATOR/
DIRECTOR:		DANIELIAN, KHATCHIKFACILITY TYPE:
740
ADDRESS:7567 BOVEY AVENUETELEPHONE:
(310) 292-2992
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 6CENSUS: 4DATE:
10/24/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Araksi Arzumanyan, Caregiver/Administrator DesigneeTIME VISIT/
INSPECTION COMPLETED:
03:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Huma Rahimi conducted a Plan of Correction (POC) visit subsequent to citation issued during the Complaint 31-AS-20240904120011 conducted on 09/30/2024. LPA met with the staff Marine Arzumanyan. The staff contacted Khatchik Danielian, the Administrator and Administrator designated the caregiver Araksi Arzumanyan who arrived at the facility shortly after. LPA explained the reason for the visit.

87411(d)(3): Personnel Requirements - General


POC: Administrator/Licensee agrees to put in writing their plan for hiring or ensuring English Speaking staff are always on shift and submit the plan by the POC date. Additionally, Administrator shall submit an updated LIC500 to reflect all staff.

During the previous visit conducted on 09/30/2024, LPA observed two staff member being scheduled; however, both staff did not communicate in English to provide care to residents. During today's visit LPA observed the same two staff available and no new staff present who can care for residents. The staff who communicates in English arrived at the facility after the staff contacted the Administrator. Based on today's observation the POC is not corrected.

Deficiency and civil penalty issued. Appeal rights explained,

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

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
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 10/24/2024 02:31 PM - It Cannot Be Edited


Created By: Huma Rahimi On 10/24/2024 at 01:24 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: LEO'S ASSISTED LIVING II
FACILITY NUMBER: 197610054

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/28/2024
Section Cited
CCR
87411(d)(3)

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87411-Personnel Requirements - General-(d):experience shall provide knowledge of and skill in the following, as appropriate for the job....effective job performance.. Skill and knowledge required to...supervision,.
This requirement is not met as evidenced by:
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Administrator/Licensee agrees to put in writing their plan for hiring or ensuring English Speaking staff are always on shift and submit the plan by the POC date. Additionally, Administrator shall submit an updated LIC500 to reflect all staff.
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Based on LPA interview with staff, the administrator did not have staff available to communicate with residents and emergency personnel effectively which poses a potential risk to the 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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Huma Rahimi
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024


LIC809 (FAS) - (06/04)
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