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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610436
Report Date: 12/11/2024
Date Signed: 12/11/2024 01:34:13 PM

Document Has Been Signed on 12/11/2024 01:34 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:DAY & NIGHT ASSISTED LIVINGFACILITY NUMBER:
197610436
ADMINISTRATOR/
DIRECTOR:		MERI MKRTUMYANFACILITY TYPE:
740
ADDRESS:17655 NORDHOFF STREETTELEPHONE:
(747) 344-3314
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 6CENSUS: 3DATE:
12/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Karen MesropyanTIME VISIT/
INSPECTION COMPLETED:
01:50 PM
NARRATIVE
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On 12/11/24, at 09:25am, Licensing Program Analyst (LPA), Gina Saucedo, conducted an unannounced
annual visit. LPA was met by resident Steven Gordon-Carroll. There was no staff present at the time of arrival. Resident Steven Gordon-Carroll called the staff and the staff-Karen Mesropyan arrived about thirty (30) minutes later.

Facility is a single-story home. Today's site visit consisted of LPA touring the physical plant by themselves since there was no staff present at the time.

Bedrooms: There is a total of five (5) bedrooms. There is a bedroom designated for staff next to the kitchen on your left-hand side. There is a total of four (4) bedrooms for resident use. All the bedrooms have proper bedding, chairs, night stands, lamps in addition to overhead lighting. There is adequate supply of linen stored in the cabinets next to the bedrooms. There was chemicals exposed to the residents. LPA took a picture of the chemicals being exposed by the washer and dryer and in the bathrooms. There are (3) bathrooms.

The facility has a working phone number land line. Fire Extinguisher located near kitchen door on your left-hand side on the floor. It is fully charged but has an expiration date.



Kitchen: Dishes, cups, and flat ware are stored in the kitchen cupboards, inspected and in good repair. Sharps are stored on your left side of the kitchen not locked and not secured accessible to residents. The cabinet was broken. Food supply adequate stored in several cabinets and consists of the following cereal, canned goods, bottles of water. Dishwasher in kitchen properly installed and functioning. The refrigerator is in good condition and working.

LIC 809C-continued
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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 11
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: DAY & NIGHT ASSISTED LIVING
FACILITY NUMBER: 197610436
VISIT DATE: 12/11/2024
NARRATIVE
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The dining/living room Resident & Staff Files:
Has enough seating for staff and residents. The furniture is in good condition. There is no resident/staff files available for LPA to review. The staff stated they believed because the residents were independent they did not have to have files and reported the residents pay in cash.

There are smoke detectors/carbon monoxide through-out the house that were tested and work properly. They are hardwired and interconnected. There is also one in each room.

The water temperature was tested for the bathrooms are they are within regulation-114-119 Fahrenheit.

Medication:
A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored in the kitchen area along with the medication was not in an area secure, locked, and inaccessible to the residents. One (1) of the residents had their own medication in their room in a bag. LPA took a picture.

Outside: LPA toured the outside area. LPA observed a covered shaded area for residents and appropriate outdoor furniture. The facility has no body of water on the premises. There is one (1) gate that is unlocked. There is a garage that is broken and needs repair.

Administration: The Liability Insurance was reviewed and will be renewed on 01/21/2026. There are several Covid 19 signs on the wall, hygiene sanitation signs, YES, Emergency Disaster Plan and Facility Grievance Procedure.

An exit interview was conducted, several citation(s) were issued and a civil penalty, appeals rights and a copy of this report was given to the administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 11
Document Has Been Signed on 12/11/2024 01:34 PM - It Cannot Be Edited


Created By: Gina Saucedo On 12/11/2024 at 12:04 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: DAY & NIGHT ASSISTED LIVING
FACILITY NUMBER: 197610436

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on the record review, the licensee did not comply with the section cited above in one documentation out of one documentation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2024
Plan of Correction
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Licensee/Administrator will need to provide documentation of insurance to LPA.
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in several cleaning supplies left exposed and accessible to the residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2024
Plan of Correction
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All disinfectants, cleaning solutions shall be immediately locked and inaccessible to all residents. A picture is to be taken and sent to the LPA.
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:Gina Saucedo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2024


LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 12/11/2024 01:34 PM - It Cannot Be Edited


Created By: Gina Saucedo On 12/11/2024 at 12:04 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: DAY & NIGHT ASSISTED LIVING
FACILITY NUMBER: 197610436

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in one out of one staff which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2024
Plan of Correction
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Cardiopulmonary resuscitation (CPR) training and first aid training shall be conducted immediately and send proof to LPA for staff working at the facility-Karen Mesropyan only staff present at the time of visit.
Type A
Section Cited
CCR
87413(a)(1)
Personnel - Operations
(1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in one out of two staff which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2024
Plan of Correction
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2
3
4
there shall be coverage by personnel with qualifications adequate to perform the assigned tasks and it shall be sent to the LPA.
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:Gina Saucedo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2024


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 12/11/2024 01:34 PM - It Cannot Be Edited


Created By: Gina Saucedo On 12/11/2024 at 12:04 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: DAY & NIGHT ASSISTED LIVING
FACILITY NUMBER: 197610436

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(f)
Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on the record review, the licensee did not comply with the section cited above in personnel records in two out of two staff which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2024
Plan of Correction
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2
3
4
All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours.
Type A
Section Cited
CCR
87412(a)(13)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in one out of two staff which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2024
Plan of Correction
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2
3
4
The criminal record of the staff currently working-Karen Mesropyan shall be conducted immediately and sent to the LPA
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:Gina Saucedo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2024


LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 12/11/2024 01:34 PM - It Cannot Be Edited


Created By: Gina Saucedo On 12/11/2024 at 12:04 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: DAY & NIGHT ASSISTED LIVING
FACILITY NUMBER: 197610436

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(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 other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on the observation, the licensee did not comply with the section cited above in three out of three residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2024
Plan of Correction
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3
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All medication from all residents shall be locked and inaccessbile to all residents immediately. A picture of locked medication and inaccessibility to residents is to be sent to the LPA.
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on the observation, the licensee did not comply with the section cited above in sharps being locked and inaccessible to all residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2024
Plan of Correction
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All sharps are to be locked immediately inaccessible to all residents. The cabinet that needs to be repaired for the sharps has to be fixed and repairs sent to LPA.
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:Gina Saucedo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2024


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 12/11/2024 01:34 PM - It Cannot Be Edited


Created By: Gina Saucedo On 12/11/2024 at 12:04 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: DAY & NIGHT ASSISTED LIVING
FACILITY NUMBER: 197610436

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on the observation, the licensee did not comply with the section cited above in two areas-the garage and the sharps cabinet being broken which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2024
Plan of Correction
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2
3
4
The cabinet in the kitchen and the garage have to be repaired and a picture or/and the receipt has to be sent to the LPA.
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on the record review, the licensee did not comply with the section cited above in one out of two staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2024
Plan of Correction
1
2
3
4
The health screening of the staff Karen Mesropyan is to be sent to the LPA immediately upon completing the necessary paperwork to work with residents.
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:Gina Saucedo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2024


LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 12/11/2024 01:34 PM - It Cannot Be Edited


Created By: Gina Saucedo On 12/11/2024 at 12:04 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: DAY & NIGHT ASSISTED LIVING
FACILITY NUMBER: 197610436

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on on the record review, the licensee did not comply with the section cited above in three out of three residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2024
Plan of Correction
1
2
3
4
All resident files is to be available to the licensing department for immediate review. All resident files is to be sent to the LPA upon completion.
Type B
Section Cited
CCR
87506(b)(13)
Resident Records
(b) Each resident's record shall contain at least the following information: (13) Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or the services he needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on the record review, the licensee did not comply with the section cited above in three out of three residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2024
Plan of Correction
1
2
3
4
Resident records showing illness, injurt and/or medical services that they need is to be kept in a file in the facility for review of the licensing department and staff/administrator to determine the resident's needs. The paperwork of the Needs and Appraisal shall be sent to the LPA.
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:Gina Saucedo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2024


LIC809 (FAS) - (06/04)
Page: 8 of 11
Document Has Been Signed on 12/11/2024 01:34 PM - It Cannot Be Edited


Created By: Gina Saucedo On 12/11/2024 at 12:04 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: DAY & NIGHT ASSISTED LIVING
FACILITY NUMBER: 197610436

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on the record review, the licensee did not comply with the section cited above in three out of three residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2024
Plan of Correction
1
2
3
4
The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal shall be kept in a file at the facility and Admission Agreement is to be sent to the LPA for each resident.
Type B
Section Cited
CCR
87506(b)(17)(E)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (E) Section 87463, Reappraisals; and

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on the record review, the licensee did not comply with the section cited above in three out of three residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2024
Plan of Correction
1
2
3
4
Documents and information required by the following: (E) Section 87463, Reappraisals; shall be kept at the above facility in a file and be sent to the LPA for all three residents.
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:Gina Saucedo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2024


LIC809 (FAS) - (06/04)
Page: 9 of 11
Document Has Been Signed on 12/11/2024 01:34 PM - It Cannot Be Edited


Created By: Gina Saucedo On 12/11/2024 at 12:04 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: DAY & NIGHT ASSISTED LIVING
FACILITY NUMBER: 197610436

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on the record review, the licensee did not comply with the section cited above in three out of three residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2024
Plan of Correction
1
2
3
4
The Pre-admission appraisal for each resident is to be kept in a file and the licensee/administrator is to review the paperwork to determine if they can take care of the residents currently living at the above facility and the pre-admission is to be sent to the LPA
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) 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
1
2
3
4
Based on the record review, the licensee did not comply with the section cited above in three out of three residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2024
Plan of Correction
1
2
3
4
The Physcian's report showing what the resident's medical diagnosis is, is to be kept at the facility and sent to the LPA.
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:Gina Saucedo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/11/2024 01:34 PM - It Cannot Be Edited


Created By: Gina Saucedo On 12/11/2024 at 12:04 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: DAY & NIGHT ASSISTED LIVING
FACILITY NUMBER: 197610436

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the record review, the licensee did not comply with the section cited above in three out of three residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2024
Plan of Correction
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The Physician's report showing an examination for communicable tuberculosis is to be kept at the above facility and sent to the LPA.
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:Troy Agard
LICENSING EVALUATOR NAME:Gina Saucedo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2024


LIC809 (FAS) - (06/04)
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