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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610176
Report Date: 04/19/2024
Date Signed: 04/19/2024 03:15:47 PM

Document Has Been Signed on 04/19/2024 03:15 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:ESSENTIAL CARE ASSISTED LIVINGFACILITY NUMBER:
197610176
ADMINISTRATOR/
DIRECTOR:		KHACHATRYAN, VERZHINEFACILITY TYPE:
740
ADDRESS:3132 WAVERLY DR.TELEPHONE:
(818) 284-7607
CITY:LOS ANGELESSTATE: CAZIP CODE:
90027
CAPACITY: 6CENSUS: 3DATE:
04/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Khachatryan VerzhineTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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On 04/19/24, 9:01 AM Licensing Program Analyst (LPA) Raymond Comer conducted a required unannounced Annual visit to this facility. LPA met with Administrator, Khachatryan Verzhine, and reason for the visit was discussed. Facility is licensed as a single-story residence, Five (5) non-Ambulatory, with one (1) bedridden for a total of six (6) Residents. Hospice waiver for six (6). Facility has three (3) resident bedrooms, one (1) bedroom area for staff use, and two (2) bathrooms.

At 9:10AM, LPA conducted a tour of the physical plant with the Administrator and observed the following:

RESIDENT RECORDS are stored in secure and locked cabinet in dining room area and are inaccessible to residents. All Resident records were reviewed, and the following documents and information were missing: Physician’s Report and Resident needs and assessment plan documentation.

STAFF RECORDS are stored in secure and locked cabinets in dining room area and are inaccessible to residents. Staff Records were reviewed and the following documents in information were missing: LIC 503 (Health Screening), LIC 501 (Personnel Record), and LIC 9052 (Employee Rights) documentation.

LIC 809C-continued
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2024
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ESSENTIAL CARE ASSISTED LIVING
FACILITY NUMBER: 197610176
VISIT DATE: 04/19/2024
NARRATIVE
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At 10:45 AM, LPA conducted a tour of the physical plant with the Administrator and observed the following:

PHYSICAL PLANT was inspected for cleanliness and condition. Facility’s main door is the primary entry/exit access. Screening area is located immediately upon entrance. Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Covid 19 prevention protocols are posted. Hand washing, coughing etiquette, and other necessary signage are posted throughout the facility. Room temperature is comfortable; wall thermostat displays a setting of 70.0°F. within the required range.
Alternative exits are located in Bedrooms #2, #3, and #4 exiting to back yard. All trash cans are observed to be covered. An approved Mitigation and Infection Control plan was submitted by the Facility. Required postings are prominently displayed and observed to be current at the facility.

COMMON AREAS: Entry and exit doors have a functional auditory alert when the doors open. Living room and Dining room areas are furnished with table large enough to accommodate the capacity of the facility. Living room is supplied with sitting area, television, stored games, and reading materials. LPA observed a fireplace in the living room area that is screened, preventing access. No fireplace tools present. Furniture and fixtures are clean and good condition. Facility telephone is observed as operational.

KITCHEN area is clean and clear of clutter. LPAs observed a refrigerator, microwave, stove/oven, dishwasher and sink to be operational. Knives/Sharps are stored in a locked top drawer inaccessible to residents. Plates, cups, utensils, and two-day supply of perishable food is properly stored. A seven-day supply of nonperishable food is located in kitchen cabinet and properly stored. Dish Soap and cleaning solutions are stored in locked lower cabinet underneath the kitchen sink.

FIRE DETECTION/SUPPRESSION SYSTEMS are present at facility. Dual smoke/carbon monoxide alarms are installed, hardwired and interconnected. Detectors were tested and function properly. Fire extinguisher is located on the wall near the kitchen and dining room. Purchase inspection service date: 04/22/2023.

LIC 809C-continued
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ESSENTIAL CARE ASSISTED LIVING
FACILITY NUMBER: 197610176
VISIT DATE: 04/19/2024
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LIC 809C-continued

MEDICATIONS are stored in a secured and locked cabinet located in the living room. Medications are inaccessible for residents. Two (2) first aid kits and manual are stored in medication cabinet.

LAUNDRY area is located outside in storage area. Laundry space observed to be clean and clear from obstructions. Soaps and other cleaning agents are stored and inaccessible to residents. A supply of linen and towels are observed to be in adequate supply.

BEDROOMS: Bedroom#1 and Bedroom#2 are shared resident rooms. Bedroom#3 is a private resident room, and Bedroom#4 is used by Staff. All Bedrooms are observed as clean with sufficient lighting, properly furnished with bedding, linens, at least one chair, and nightstand.

BATHROOMS were observed to be clean and sanitary with necessary supplies and required safety fixtures (grab bars, anti-slip floor stripping). Hot water temperature measured at 104°F. Within the required range.

GARAGE is detached from the house and observed to be locked and inaccessible to residents. Garage is storage for miscellaneous items.

OUTDOORS: Backyard area observed to be clean and clear from debris and obstruction. Outdoors maintains a shaded area with patio furniture observed to be in good condition and sufficient seating for residents. Backyard contains a swimming pool whose perimeter is fenced, and entry gate secured and locked, inaccessible to residents.



(See LIC809D for Deficiencies Cited)
.
An Exit Interview was Conducted, A copy of the Facility Report and Appeal Rights were provided to the Administrator.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 04/19/2024 03:15 PM - It Cannot Be Edited


Created By: Raymond Comer On 04/19/2024 at 01:44 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: ESSENTIAL CARE ASSISTED LIVING
FACILITY NUMBER: 197610176

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
84712(a)


87412(a) Personnel Records. he licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee.This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in (2) out of (2) total Staff files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2024
Plan of Correction
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Administrator shall complete all personnel files with all required documentation and submit to CCL a statement stating of completion and understanding that all files will be up to date as required.
Type B
Section Cited
CCR
80068.2


80068.2(a) Needs and Services Plan. The licensee shall complete a Needs and Services Plan for each client. This requirement is not met as evidenced by:

1. No needs and service plan for resident#1, resident#2, and resident#3.
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in (3) out of (3) total Residents,which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2024
Plan of Correction
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Administrator shall ensure that each Resident's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually. These modifications shall be maintained in the Resident's file.
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:Eva Miller
LICENSING EVALUATOR NAME:Raymond Comer
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024


LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 04/19/2024 03:15 PM - It Cannot Be Edited


Created By: Raymond Comer On 04/19/2024 at 02:24 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: ESSENTIAL CARE ASSISTED LIVING
FACILITY NUMBER: 197610176

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87569(a)(b)


Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in (1) out of (3) total Residents which poses/posed a potential health, safety or personal rights risk to persons in care.
LPA observed resident #2 was missing her Physician's Report - (LIC 602).

POC Due Date: 04/30/2024
Plan of Correction
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Administrator will see that all resident's files are complete, and they include Physician's Report - LIC 602. Submit a copy of resident's LIC 602 to CCL by 4/30/24 as proof of correction.
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:Eva Miller
LICENSING EVALUATOR NAME:Raymond Comer
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024


LIC809 (FAS) - (06/04)
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