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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610419
Report Date: 06/06/2024
Date Signed: 06/07/2024 03:23:47 PM

Document Has Been Signed on 06/07/2024 03:23 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ALL STAR CARE INCFACILITY NUMBER:
197610419
ADMINISTRATOR/
DIRECTOR:		DARABEDYAN, IVETAFACILITY TYPE:
740
ADDRESS:36240 52 ST EASTTELEPHONE:
(818) 624-6006
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY: 6CENSUS: 0DATE:
06/06/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:09 PM
MET WITH:Iveta DarabedyanTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On 06/06/2024 Licensing Program Analyst (LPA) Melissa Spaeth initiated a complaint investigation for Complaint #31-AS-20240602100413. LPA Spaeth requested to review the resident's files. However, the Administrator stated they were unable to obtain the required documentation from the residents. LPA stated to the Administrator it is important to obtain all documentation before the move-in date. The Administrator stated they will make sure all documentation is obtained when admitting any resident.

Based upon LPA's observation and interview of the Administrator, the following deficiency will be issued.

Exit interview conducted, appeal rights discussed, and a copy of the report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2024
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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Document Has Been Signed on 06/07/2024 03:23 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 06/06/2024 at 02:11 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: ALL STAR CARE INC
FACILITY NUMBER: 197610419

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/07/2024
Section Cited
CCR
87506(a)

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87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility...This is evidenced by:
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The Administrator will review regulation 87506 and send an email to LPA Spaeth confirming the Administrator did review the regulation.
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The Licensee failed to obtain resident records for each resident living in the facility. This poses a potential health, safety or personal rights risk to persons 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:Troy Agard
LICENSING EVALUATOR NAME:Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024


LIC809 (FAS) - (06/04)
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