Community Care Licensing

Document Has Been Signed on 01/06/2025 03:10 PM - It Cannot Be Edited

FACILITY NAME:	SAFEWAY SENIOR LIVING		FACILITY NUMBER:	197610502
ADMINISTRATOR/ DIRECTOR:	SARGSYAN, ANNA		FACILITY TYPE:	740
ADDRESS:	15725 LEMARSH STREET		TELEPHONE:	(818) 344-5555
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY: 6		CENSUS: 5	DATE:	01/06/2025
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:30 AM
MET WITH:	SARGSYAN, ANNA- Licensee		TIME VISIT/ INSPECTION COMPLETED:	03:49 PM

SUPERVISORS NAME: Nichelle Gillyard LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2025

Link to Parent Document Below:

FACILITY NAME: SAFEWAY SENIOR LIVING	FACILITY NUMBER: 197610502
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/06/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/20/2025 Section Cited CCR 87411(c)	1 2 3 4 5 6 7	All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69.	1 2 3 4 5 6 7	Licensee will conduct a training for themselves and staff and submit attendance sheet by the POC date.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on observation, administrator and staff needs training which disrupts the comfort and health of others which poses a potential health, safety and personal rights risk to clients in care.	8 9 10 11 12 13 14
Type B 01/13/2025 Section Cited CCR87507(c)	1 2 3 4 5 6 7	Written in clear, understandable, coherent, and unambiguous language, using words with common and everyday meanings, and shall be appropriately divided with each section appropriately titled.	1 2 3 4 5 6 7	Licensee agree to provide admission agreement to everyone.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on observation, administrator did not provide admission agreement upon taking in a resident which disrupts the comfort and health of others which poses a potential health, safety and personal rights risk to clients in care.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Nichelle Gillyard LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2025

Link to Parent Document Below:

FACILITY NAME: SAFEWAY SENIOR LIVING	FACILITY NUMBER: 197610502
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/06/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/13/2025 Section Cited CCR 87506(a)(b)	1 2 3 4 5 6 7	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. ach resident’s record shall contain at least the following information:	1 2 3 4 5 6 7	Administartor agrees to have all the necessary paperwork done when onboarding residents to the facility.
	8 9 10 11 12 13 14	Name; DOB, SSN, physician information, etc. This requirement is not met as evidenced by: Based on record review, administrator did not provide five (5) residents records to LPA which disrupts the comfort and health of others which poses a potential health, safety and personal rights risk to clients in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

SUPERVISOR'S NAME: Nichelle Gillyard LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2025

Link to Parent Document Below:

FACILITY NAME: SAFEWAY SENIOR LIVING	FACILITY NUMBER: 197610502
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/06/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/07/2025 Section Cited CCR 873511(a)	1 2 3 4 5 6 7	A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department: (1) A signed Criminal Background Clearance Transfer Request, LIC 9182	1 2 3 4 5 6 7	Administrator will send proof of association or will send an association documents for S2 and S3 to CCL on or before the POC date, if unable to log in at Guardian.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on record review, licensee did not ensure that S2 and S3 is associated at this facility which poses an immediate health, safety and personal rights risk to the residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

SUPERVISOR'S NAME: Nichelle Gillyard LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2025