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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610305
Report Date: 10/25/2022
Date Signed: 10/25/2022 01:41:32 PM

Document Has Been Signed on 10/25/2022 01:41 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:BRIGHTSTAR SENIOR CARE,INCFACILITY NUMBER:
197610305
ADMINISTRATOR:ALLAHDADI, AYEDEHFACILITY TYPE:
740
ADDRESS:10455 GAYNOR AVETELEPHONE:
(818) 517-0544
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 4DATE:
10/25/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Ayedeh AllahdadiTIME COMPLETED:
01:55 PM
NARRATIVE
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the home in response to complaint number 31-AS-20221020145038. The LPA had his temperature taken before being allowed entry in the home.

While touring the home, the LPA observed a bed in the living room that a resident had been sleeping in. The administrator was notified that this is not allowed. The administrator stated that the resident had requested the bed be placed in the living room because the couch was not comfortable. The LPA explained that this is not allowed.

Exit interview conducted, deficiency cited and report issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2022
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 10/25/2022 01:41 PM - It Cannot Be Edited


Created By: Patrick Shanahan On 10/25/2022 at 01:23 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: BRIGHTSTAR SENIOR CARE,INC
FACILITY NUMBER: 197610305

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/26/2022
Section Cited
CCR
85087(a)(3)

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Buildings and Grounds. No room used as a common area shall be used as a bedroom for any person
This requirement was not met as evidenced by:
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Administrator removed bed during visit.

Cleared during visit
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The administrator did not prevent a resident from using the living room as a bedroom, 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:Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022


LIC809 (FAS) - (06/04)
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