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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610255
Report Date: 09/22/2022
Date Signed: 09/22/2022 11:43:52 AM

Document Has Been Signed on 09/22/2022 11:43 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:AMAZING SENIOR CARE ON LASSEN, INC.FACILITY NUMBER:
197610255
ADMINISTRATOR:ALADADYAN, YELENAFACILITY TYPE:
740
ADDRESS:17127 LASSEN STTELEPHONE:
(818) 207-4220
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 6CENSUS: 4DATE:
09/22/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Anna Petrosyan TIME COMPLETED:
11:50 AM
NARRATIVE
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On 09/22/22 Licensing Program Analyst (LPA) conducted an unannounced complaint investigation visit for complaint #31-AS-20220921151917. Upon arrival LPA was greeted by staff and the purpose of the visit was explained.

LPA Martinez toured the facility for any immediate health or safety concerns. During the course of the tour, LPA observed a staff assisting a resident. LPA asked for the name of the staff to determine it staff has been fingerprinted, cleared, and associated to the facility. According to a telephone interview with administrator the staff is a volunteer and has only volunteered for two days. Administrator stated volunteer went to go get fingerprinted two days ago. LPA reminded that anyone working directly with residents must receive clearance prior to their start date. Volunteer was sent home during the visit. Administrator was not able to sign during exit interview and approved for designee to sign the report.

Immediate civil penalties of one hundred dollars ($100) per day has been issued. Exit interview conducted. Report signed and delivered. Appeal rights issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2022
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 09/22/2022 11:43 AM - It Cannot Be Edited


Created By: Joscelyn Martinez On 09/22/2022 at 11:09 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: AMAZING SENIOR CARE ON LASSEN, INC.
FACILITY NUMBER: 197610255

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/22/2022
Section Cited
CCR
87355(e)(1)

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87355 (e)(1) Criminal Record Clearance
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or..
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This is a zero tolerance violation. Volunteer was sent home during the visit. LPA stated to administrator they cannot come back until they are cleared and associated. Immediate civil penalty of $100 x 2 days has been issued for a total of $200.
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This requirement is not met as evidenced by:

LPA observed volunteer assisting R1 in the bedroom. Volunteer working at the facility prior to obtaining criminal record clearance which poses 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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022


LIC809 (FAS) - (06/04)
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