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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850089
Report Date: 05/09/2023
Date Signed: 05/09/2023 02:23:35 PM


Document Has Been Signed on 05/09/2023 02:23 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:MARY ELLEN HOMESFACILITY NUMBER:
195850089
ADMINISTRATOR:KHACHATRYAN, GOHARFACILITY TYPE:
740
ADDRESS:7752 MARY ELLEN AVENUETELEPHONE:
(818) 279-1415
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:6CENSUS: 6DATE:
05/09/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Gohar KhachatryanTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sandra Uena conducted an unannounced Case Management-Deficiencies inspection visit at the facility today due to deficiencies observed during the investigation of complaint control #29-AS 20230505112637.

At 1:30 p.m., LPA Urena interviewed the Administrator and requested the personnel file for S2. The administrator stated that S2 was not background cleared, nor associated to the facility. The administrator stated that they had hired S2 approximately around 5/1/2022, to assist residents with showers. S2 was last present at the facility the morning of 5/9/2023 to provide a letter to administrator of actions taken while providing services to residents.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):



Exit interview conducted, today's reports and appeal rights were reviewed and issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023
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 05/09/2023 02:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: MARY ELLEN HOMES
FACILITY NUMBER: 195850089

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/12/2023
Section Cited

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87355 Criminal Record Clearance(e)(1): All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... in a licensed facility:(1) Obtain a California clearance or a criminal record exemption as required by the Department .
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Licensee agreed to only employ staff that have obtained a criminal record clearance and are associated to the facility. Administrator understands that the individual cannot be present at the facility until they have obtained criminal record clearance.
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This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above as the licensee did not ensure that S2 was associated prior to allowing S2 to work, which poses an immediate health and safety 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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023
LIC809 (FAS) - (06/04)
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