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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610102
Report Date: 11/23/2021
Date Signed: 11/23/2021 01:33:05 PM

Document Has Been Signed on 11/23/2021 01:33 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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ALLEVIATE CAREFACILITY NUMBER:
197610102
ADMINISTRATOR:ESTRADA, LOURDES MFACILITY TYPE:
740
ADDRESS:20930 GAULT STREETTELEPHONE:
(818) 378-2772
CITY:CANOGA PARKSTATE: CAZIP CODE:
91303
CAPACITY: 6CENSUS: DATE:
11/23/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Edgar GhazaryanTIME COMPLETED:
01:32 PM
NARRATIVE
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lOn 11/23/2021 at 12:20 PM, Licensing Program Analyst (LPA) Nicholas Reed noted deficiencies from an unannounced annual visit earlier in the day. LPA met with Administrator to discuss the deficiencies LPA observed.

The census of residents was 7

During a facility tour at approximately 10:15 AM, LPA observed two residents in Bedroom #6, one resident in Bedroom #3, one resident in the living room, one resident in Bedroom #2, and two residents in Bedroom #1. The facility currently provides service to 7 residents.

Additionally, one of the two residents in Bedroom #1 was non-ambulatory. From records review and discussion with Administrator, LPA learned Bedroom #1 is designated for ambulatory use only.

Administrator noted the reasons for operating beyond the facility’s fire clearance. Administrator accepted Emergency Placements recently, and due to additional, necessary medical procedures and family requests, Administrator retained an extra resident. Two residents were expected to leave by December 1st, so Administrator did not initiate the 30-day eviction process.

Pursuant to Title 22 Division 6 Chapter 8 Article 4 of the CA Code of Regulations, deficiencies were cited (refer to LIC 809-D).

Exit Interview conducted, appeal rights discussed and issued, and copy of report emailed to Administrator.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/23/2021
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 11/24/2021 01:40 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 11/24/2021 08:25 AM


Created By: Nicholas Reed On 11/23/2021 at 01:09 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ALLEVIATE CARE
FACILITY NUMBER: 197610102

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/24/2021
Section Cited
CCR
87204(a)

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****This document was amended to include necessary language**** 87204 Limitations - Capacity and Ambulatory Status (a) A licensee shall not operate a facility beyond the limitations specified on the license, including specification of the maximum number of persons who may receive services at any time.
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Administrator will seek outside placement for the extra resident today and verify the resident's move by 11/24/2021 to LPA in person.
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This requirement was not met as evidenced by:
Based on LPA observation, interview, and record review, it was determined the Licensee operated beyond the faciilty's maximum approved fire clearance for 6 residents. This posed an immediate health and safety risk to residents in care.
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Type A
11/24/2021
Section Cited
CCR87204(b)

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87204 Limitations - Capacity and Ambulatory Status
(b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents.

This requirement is not met as evidenced by:
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Administrator will seek outside placement for the resident today and verify the resident's move by 11/24/2021 with LPA in person.
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Based on LPA observation and interview, it was determined the Licensee placed a non-ambulatory resident in a room with fire clearance designated for ambulatory residents only. This posed an immediate health and safety risk to 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:Cassandra Harris
LICENSING EVALUATOR NAME:Nicholas Reed
LICENSING EVALUATOR SIGNATURE:
DATE: 11/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/24/2021


LIC809 (FAS) - (06/04)
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