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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610083
Report Date: 10/21/2022
Date Signed: 10/21/2022 11:54:27 AM

Document Has Been Signed on 10/21/2022 11:54 AM - 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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:SAINT MARY'S RESIDENTIAL CAREFACILITY NUMBER:
197610083
ADMINISTRATOR:YEGEYAN, NAZARFACILITY TYPE:
740
ADDRESS:17177 1/2 SAN JOSE STREETTELEPHONE:
(818) 403-1803
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 5DATE:
10/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Nazar Yageyyan/ AdministratorTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility in order to conduct an infection control annual. The LPA was greeted by facility staff and had his temperature taken and signed in before being allowed entry. The administrator was called and arrived a short while later. The staff and the administrator were explained the reason for the visit.

The LPA was able to briefly tour the home. The home has 3 bedrooms and 2 bathrooms. A functional fire extinguisher was observed in the living room and in the kitchen. The smoke alarms and carbon monoxide detectors were tested and functioned properly. While touring the home, the LPA did observe bleach and detergent on the floor and accessible to residents in care.

The inspection was tool was used to complete this visit.

Exit interview conduct, deficiencies cited, and report issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2022
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 10/21/2022 11:54 AM - It Cannot Be Edited


Created By: Patrick Shanahan On 10/21/2022 at 11:40 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: SAINT MARY'S RESIDENTIAL CARE
FACILITY NUMBER: 197610083

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
87705(f)(2)
87705 (f)(2) Care of Persons with Dementia 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
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Based on observation, the licensee did not comply with the section cited above in in that two (2) bottles of chemicals next to the washing machine and accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2022
Plan of Correction
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Cleared during visit
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2022


LIC809 (FAS) - (06/04)
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