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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610489
Report Date: 04/10/2024
Date Signed: 04/10/2024 02:52:37 PM

Document Has Been Signed on 04/10/2024 02:52 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:VELVET CARE 2FACILITY NUMBER:
197610489
ADMINISTRATOR/
DIRECTOR:		PAROYAN, NAIRAFACILITY TYPE:
740
ADDRESS:16909 CITRONIA STREETTELEPHONE:
(310) 480-2009
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 6CENSUS: 5DATE:
04/10/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Hayk Kirokosyan- LicenseTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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On 04.10.2024 in conjunction with an initial complaint visit control number 31-AS-20240409084443. Licensing Program Analyst (LPA) Leslie Ngo-Castaneda completed an unannounced CASE MANAGEMENT- Deficiencies visit. LPA met with Licensee Hayk Kirokosyan, explained the purpose of the visit.

From 10:30AM to 11:30AM, LPA interviewed four (4) out of four (4) staff and four (4) out of five (5) residents. During the interview R2 advised LPA that their bedroom #4 is used as a passageway for staff to use the exit door to gain entrance to the garage. R2 stated that staff would just barged into their bedroom without knocking. Because of such action staff is violating the residents personal rights for privacy.

Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiency was observed and cited (Refer to LIC 809-D).

Copy of this report provided, appeal rights given. Exit interview conducted.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2024
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 04/10/2024 02:52 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 04/10/2024 at 01:53 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: VELVET CARE 2
FACILITY NUMBER: 197610489

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/24/2024
Section Cited
CCR
87468.2(A)(1)

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To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups.
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Licensee/administrator will submit a written statement notifying the department what steps will be taken to clear this deficiency and
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This requirement is not met as evidenced by: Staff would just barged into bedroom #4 without knocking in order to gain access for the exit doors that leads to the garage.
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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:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024


LIC809 (FAS) - (06/04)
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