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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850143
Report Date: 05/06/2024
Date Signed: 05/06/2024 07:15:16 PM

Document Has Been Signed on 05/06/2024 07:15 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:A COMPASSION VALLEYFACILITY NUMBER:
195850143
ADMINISTRATOR/
DIRECTOR:		KUYUMCHYAN, BREANNAFACILITY TYPE:
740
ADDRESS:7460 MAMMOTH AVE.TELEPHONE:
(818) 983-9165
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY: 6CENSUS: 5DATE:
05/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Eva Elizalde, StaffTIME VISIT/
INSPECTION COMPLETED:
07:20 PM
NARRATIVE
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Licensing Program Analyst(LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool. LPA Yee was let into the home by Gulnara Abdrakhmanova, Staff. Staff attempted to contact Breanna Kuyumchyan, Administrator but was unsuccessful and she did not participate in today's visit. Staff then contacted Eva Elizalde and she was advised by LPA Yee the reason for today's visit. Eva Elizalde arrived at 11:03am to conduct the visit.

The home is a single storey family home consisting of a living room, dining room, kitchen, 4 bedrooms of which one is designated for live-in staff, 3 full bathrooms and a attached garage. The facility is fire cleared for 4 NON-AMBULATORY and 2 AMBULATORY residents. The facility is approved for 6 hospice waiver.

The following domains were reviewed and completed on today's visit: Operational Requirements, Physical Plant/Environmental Safety and partially reviewed were: Staffing, Resident Rights/Information and Residents with Special Health Needs. A return visit will be conducted to complete the inspection. A tour of the facility inside was conducted and the carbon monoxide and smoke detectors were tested and were operational.

The following was observed on today's visit:
  • The living room, dining room and kitchen were toured and they were equipped and furnished with the appropriate seating, furnishing and equipment for 6 residents.
  • Bedroom #1 was observed with 2 twin beds, a shared dresser, 2 night stands, 2 chairs with worn out covers, 2 lamps, a television and a closet. The blinds are missing slates. Per information provided, the room is for designated for staff use. Upon arrival, a resident was observed sleeping in the left bed.
  • the common bathroom was observed with a shower, grab bars, a single sink vanity and storage cabinets. Diapers and supplies were observed. Also observed was a can of pledge, a can of air
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: A COMPASSION VALLEY
FACILITY NUMBER: 195850143
VISIT DATE: 05/06/2024
NARRATIVE
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  • freshner, perfumes and hand sanitizer.
  • Bedroom #2 was observed with 2 twin beds, 1 lamp, 1 shared dresser, 2 night stands, 1 chair, 1 shared closet. No flat sheets were observed. The blinds on the window facing the back was observed missing slates. Located inside the room is a private bathroom equipped with a shower, a toilet and a single sink vanity. Grab bars and a non-skid mat was observed. The bathroom window looks off track and may be broken. The water temperature was tested and read 119.6 degrees Fahrenheit.
  • Bedroom #3 was observed with 2 two beds, 2 night stands, 1 dresser, 1 shared closet, no chairs or lamps were observed. The bed to the left side of the room was obsejrved with a bed rail placed along the middle of the bed. No flat sheets were observed in use. A sixth resident was observed in the left bed. Per information provided, the facility was caring for a friend of a family member. Resident was relocated during today's visit.
  • Bedroom #4, located behind the dining room was observed with a twin bed and a hospital bed, 2 night stands, 2 chairs, 1 dresser, a closet. The beds were observed with no flat sheet and blanket was observed on a chair. The Resident in the right hospital bed with a full bed rail was observed using oxygen and there are no signs posted anywhere in the facility to indicate that oxygen is in use. Per information provided by staff, the fire department has not been notified in writing that oxygen is in use at the facility as required by Title 22. Located alongside the room is a private bathroom equipped with a large jacuzzi tub, a shower, a toilet and a single sink vanity. Due to the inaccessibility of the bathroom to residents who are determined to be non-ambulatory an entry door was added from the outside and designated for staff use.
  • The hardwired smoke detectors in the residents rooms, the dining room, living room and the smoke/carbon monoxide combination detector located by the front door were tested and were operational.
  • All the outside exiting doors - front door, kitchen door, sliding glass door (bedroom #3) and bathroom door(bedroom #4), were equipped with auditory devices which were either not operational or turned off during the tour and the facility accepts and has retained a resident diagnosed with dementia.
  • The facility has a land line - (818)616-4324.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Any deficiencies not addressed on today's visit, will be addressed on a return visit.
Exit interview was conducted.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
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Document Has Been Signed on 05/06/2024 07:15 PM - It Cannot Be Edited


Created By: Christine Yee On 05/06/2024 at 04:56 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: A COMPASSION VALLEY
FACILITY NUMBER: 195850143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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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4
Based on observation, the licensee did not comply with the section cited above per tour of the common bathroom, a can of pledge, air freshner, hand sanitizer, perfumes were stored in an unlocked cupboard located in the bathroom and the facility accepts residents with dementia and has retained one resident diagnosed with dementia, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/07/2024
Plan of Correction
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4
The Licensee will ensure that all poisons/toxins that may be ingested by persons with dementia are secured and made inaccessible to residents in care by 5/7/24
Type A
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 counts out of 6 beds observed with residents, Resident #1 was in a bed equipped with a full bed rail and does not have a doctor's order for it's use. Also observed in bedroom #3 was an individual who the staff is baby sitting in a bed with a bed rail placed in the middle of the bed to prevent the person from getting out of bed, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/07/2024
Plan of Correction
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The Licensee will ensure that all residents beds are not equipped with full bedrails unless the proper physician's order and exception for the use of the full bedrails are granted by the Department. Licensee will remove the bedrails and provide evidence to the Department by 5/7/24
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:Kristin Heffernan
LICENSING EVALUATOR NAME:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2024


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Document Has Been Signed on 05/06/2024 07:15 PM - It Cannot Be Edited


Created By: Christine Yee On 05/06/2024 at 04:56 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: A COMPASSION VALLEY
FACILITY NUMBER: 195850143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above per tour of the common bathroom, the shower stall did not contain a non-skid mat which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2024
Plan of Correction
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Licensee will ensure that all facility shower stalls are equipped with a non-skid mat. Provide evidence of correction by no later than 5/13/24
Type B
Section Cited
CCR
87303(f)(4)
Maintenance and Operation
(f) Solid waste shall be stored and disposed of as follows: (4) Movable bins when used for storing or transporting solid wastes from the premises shall have tight-fitting covers on the containers; shall be in good repair; and shall be rodent-proof unless stored in a room or screened enclosure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 4 out of 5 counts, the 2 green trash cans, 1 blue trash can and 1 black trash can stored alongside the garage were observed to be cracked and had holes in the lids, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2024
Plan of Correction
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Licensee will contact the city to obtain new trash cans to replace the trash cans that havecracks and holes in the lids. Provide evidence of correction by 5/13/24
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:Kristin Heffernan
LICENSING EVALUATOR NAME:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2024


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 05/06/2024 07:15 PM - It Cannot Be Edited


Created By: Christine Yee On 05/06/2024 at 04:56 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: A COMPASSION VALLEY
FACILITY NUMBER: 195850143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(h)
Maintenance and Operation
(h) Emergency lighting shall be maintained. At a minimum this shall include flashlights, or other battery powered lighting, readily available in appropriate areas accessible to residents and staff. Open-flame lights shall not be used.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview with staff, the licensee did not comply with the section cited above as the facility could not provide evidence that the facility has any flashlights with extra batteries to make it easily available to residents or staff, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2024
Plan of Correction
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Licensee will ensure that there is emergency lighting provided and available to the residents and staff during an emergency. Licensee will purchase emergency lighting and provide the Department with evidence of correction by 5/13/24
Type B
Section Cited
CCR
87307(a)(3)(B)
Personal Accommodations and Services
(B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above per tour of the resident's room, bedroom #2 is missing a chair and bedroom #3 does not have any chairs for resident use which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2024
Plan of Correction
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Licensee will provide a chair in bedroom #2 and provide 2 chairs in bedroom #3. Provide evidence of correction by 5/13/24
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:Kristin Heffernan
LICENSING EVALUATOR NAME:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/06/2024 07:15 PM - It Cannot Be Edited


Created By: Christine Yee On 05/06/2024 at 04:56 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: A COMPASSION VALLEY
FACILITY NUMBER: 195850143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(3)(C)
Personal Accommodations and Services
(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation], the licensee did not comply with the section cited above per tour of the bedrooms, the residents beds were not provided with flat sheets which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2024
Plan of Correction
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Licensee will ensure that all the resident beds are provided with a mattress cover, a fitted sheet, a flat sheet, a blanket and a bedspread. Licensee will purchase flat sheets if none is available and place them on the residents beds. Provide evidence that the correction has been completed by no later than 5/13/24.
Type B
Section Cited
CCR
87618(b)(3)(A)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (A) A report shall be made in writing to the local fire jurisdiction that oxygen is in use at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview , the licensee did not comply with the section cited above in 1 out of 1 count, the Licensee did not file a written notification to the local fire department that oxygen is in use at the facility,which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2024
Plan of Correction
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Licensee will ensure that a written notice is provided to the local fire department for the use of oxygen in the facility. Licensee will provide a written notice to the fire department by 5/13/24 for Resident #1's use of oxygen. Provide evidence that the deficiency was corrected.
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:Kristin Heffernan
LICENSING EVALUATOR NAME:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2024


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 05/06/2024 07:15 PM - It Cannot Be Edited


Created By: Christine Yee On 05/06/2024 at 04:56 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: A COMPASSION VALLEY
FACILITY NUMBER: 195850143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above per tour of the facility, it was observed that Resident #1 uses oxygen and there were no signs posted to advise that there is "NO Smoking-oxygen in use" at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/07/2024
Plan of Correction
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3
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Licensee will ensure that posters stating that there is "NO Smoking-oxygen in use" posted in all the appropriate areas by 5/7/24. ***************Corrected -posters were placed on Resident #1 bedroom door and front door during this visit. A third poster will be posted on the kitchen door that leads to the garage.*******************
Type B
Section Cited
CCR
87705(j)
87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above per tour of the facility, all outside exit doors were observed with auditory devices - front door, kitchen door, Bedroom #3 that did not work or were turned off and there were no auditory device observed in the back door leading out of Bedroom #4 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2024
Plan of Correction
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2
3
4
Licensee will ensure that all auditory devices are operational all times. Licensee will inspect the auditory devices to ensure that they are still operational and replace if it is not and install an auditory device on the door in the back door of bedroom #4. Provide evidence that the auditory devices are operational and one was installed in bedroom #4 by 5/13/24
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:Kristin Heffernan
LICENSING EVALUATOR NAME:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2024


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 05/06/2024 07:15 PM - It Cannot Be Edited


Created By: Christine Yee On 05/06/2024 at 06:04 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: A COMPASSION VALLEY
FACILITY NUMBER: 195850143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(6)
87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above per tour of the facility, LPA Yee attempted to exit from the front door and observed that a latch had been installed at the very top of the door to prevent the door from opening..
POC Due Date: 05/07/2024
Plan of Correction
1
2
3
4
Licensee will ensure that the facility doors are not locked or barred to prevent the residents from leaving or departing from the facility at any time and not to be locked into any room, building, or on facility premises by day or night. ***corrected when LPA requested that the latch be immediately remvoed during the visit*******************
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Kristin Heffernan
LICENSING EVALUATOR NAME:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2024


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