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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610306
Report Date: 10/28/2024
Date Signed: 10/28/2024 03:50:16 PM

Document Has Been Signed on 10/28/2024 03:50 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:ASSISTED SENIOR CARE FACILITYFACILITY NUMBER:
197610306
ADMINISTRATOR/
DIRECTOR:		AGHABEKYAN, GAYANEFACILITY TYPE:
740
ADDRESS:7039 CLAIRE AVETELEPHONE:
(818) 578-5958
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 6CENSUS: 6DATE:
10/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Rima Agaronyan, Administrator DesigneeTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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At 01:00 PM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced annual visit. LPA met with the Administrator Designee Rima Agaronyan, and disclosed the reason for the visit. LPA and the Administrator Designee toured the facility inside and out.

Kitchen: At 1:18 PM, LPA and Administrator Designee toured the kitchen and the kitchen is equipped with a refrigerator, microwave oven and sink. There were adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). Knives were observed locked in the kitchen drawer.

MEDICATIONS: LPA observed the medication locked and inaccessible to residents in care in a cabinet in the dinning room; however, bedroom # (1) closet of a resident had two Ziplock bags filled with medications of one of the caregivers accessible to the resident in care. Additionally, LPA observed more medications in all residents bedrooms accessible to residents in care.



SAFETY: The smoke alarms and carbon monoxide detector are battery operated. The facility has a fire extinguishers that was purchased on 09/07/2024. One fire extinguisher is located on the kitchen wall.

BEDROOMS: There are five (5) bedrooms designated for resident’s use. Bedroom # (3) is shared. All other four (4) bedrooms are private. Bedroom number one is cleared for bedridden. All other rooms are cleared for non-ambulatory. All bedrooms are furnished with beds, night stand, chairs, dresser, bedding and linen. The bedrooms have sufficient lighting and closet space.

BATHROOMS: The facility has three (3) bathrooms. The bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured between 116.08 degrees.
Continue on LIC 809C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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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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: ASSISTED SENIOR CARE FACILITY
FACILITY NUMBER: 197610306
VISIT DATE: 10/28/2024
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COMMON AREAS: These included the TV and activity room which were equipped with living room furniture, a television, tables and chairs. The dining area has a large dining room table to accommodate six (6). There were no visible immediate hazards.

LAUNDRY ROOM: The laundry room is located in the in the hall. All the cleaning supplies and detergents were observed locked in a storage area in bedroom # (3).

OFFICE/STAFF WORKSTATION: Staff workstation is located at the entrance of the facility.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. The backyard of the facility has a patio and outdoor furniture to accommodate the six (6) residents. The facility backyard has sufficient yard space. There is only one emergency exit and LPA observed free of obstruction and hazard. The gate had a inward latch.

Between 3:00 PM to 4:00 PM, LPA reviewed records of three (3) residents and two (2) staff. Residents and staff records appeared to be complete and updated

Administrative: LPA collected Certificate of Liability Insurance, and LIC500.

A deficiency cited during today’s visit. Appeal Rights explained.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/28/2024 03:50 PM - It Cannot Be Edited


Created By: Huma Rahimi On 10/28/2024 at 03:29 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: ASSISTED SENIOR CARE FACILITY
FACILITY NUMBER: 197610306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
7465 Incidental Medical and Dental Care(h)The following requirements shall apply to medications which are centrally stored(2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations the caregiver medications were unlocked in a resident closet as well as other medications accessible in all of the residents bedrooms' closets. The Administrator did not ensure that the centrally stored medications were locked and inaccessible to resident in care. This poses an immediate health and safety
hazard to residents in care.
POC Due Date: 10/30/2024
Plan of Correction
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During the visit the administrator designee Rima Agaronyan immediately removed the caregiver medications and as well locked all the other residents medications. The administrator will do an in service with staff to ensure medication are secured, and they are locked after each use and each time after opening the medication drawer. Documentation will be submitted as proof of correction with staff names and date and training material used.
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:Huma Rahimi
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
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