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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850143
Report Date: 05/23/2023
Date Signed: 05/23/2023 04:53:14 PM


Document Has Been Signed on 05/23/2023 04:53 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:A COMPASSION VALLEYFACILITY NUMBER:
195850143
ADMINISTRATOR:KUYUMCHYAN, BREANNAFACILITY TYPE:
740
ADDRESS:7460 MAMMOTH AVE.TELEPHONE:
(818) 983-9165
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY:6CENSUS: 6DATE:
05/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:16 AM
MET WITH:Eva ElizaldeTIME COMPLETED:
05:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angel Ascencio arrived at the facility unannounced to conduct a required Annual visit. The LPA met with Staff upon arrival, and explained the reason for the visit. Administrator Breanna Kuyumchyan was not able to meet LPA but authorized Staff Eva Elizalde to sign documents. Entrance interview conducted.

The LPA, with the guidance of staff, toured the physical plant areas inside and outside to ensure there are no


health and safety hazards and facility is in compliance with Title 22 Regulations.

BEDROOMS: All client rooms are set up with beds, night stands, lamps, chests of drawers,
chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean
linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a
bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for
easy passage between the beds. In addition, no bedroom was used as a passageway to another
room, bath or toilet. There are four (4) total rooms - one (1) is a staff room, and three (3) are shared resident rooms.

RESTROOMS: There are three (3) total bathrooms at the home. The resident bathroom has a shower with
non-skid materials. The toilet and shower have grab bars. During the visit, the LPA observed signs in all of the bathrooms pertaining to proper hand hygiene. All cleaning supplies were inaccessible to client in care. In
addition, restroom hot water measured under 120.0 degree F.

KITCHEN: Kitchen knives are stored in a locked closet by the kitchen. The supply of dishes, utensils, pots,
pans and drink ware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the
refrigerator was maintained at 40*F.
Continued on LIC 809 - C
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2023
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 05/23/2023 04:53 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: A COMPASSION VALLEY
FACILITY NUMBER: 195850143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and medication review, the licensee did not comply with the section cited above in R1 did not have their entire medication present at the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/25/2023
Plan of Correction
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Administrator will conduct an medication audit for all resident to ensure all medication is present and counter for.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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 HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 18


Document Has Been Signed on 05/23/2023 04:53 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: A COMPASSION VALLEY
FACILITY NUMBER: 195850143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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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Based on staff file review, the licensee did not comply with the section cited above in 5 out of 5 staff members did not have their 1st Aid/CPR certification which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2023
Plan of Correction
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Administrator will have all staff members obtain their CPR/1st aid Certification. Administrator will submit the documents to CLL by 06/09/2023.
Type B
Section Cited
CCR
87412(a)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 1 staff member did not have their personnel file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2023
Plan of Correction
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The Administrator will read Title 22 Section 87412 and will ensure that all the documents required in all the staff's files are maintained in the staff files. The Administrator will submit all documents for staff to CCL by 06/09/2023.
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 HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2023
LIC809 (FAS) - (06/04)
Page: 3 of 18


Document Has Been Signed on 05/23/2023 04:53 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: A COMPASSION VALLEY
FACILITY NUMBER: 195850143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(12)
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: (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General.

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 as 4 out of 5 staff member did not have their TB test in personnel files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2023
Plan of Correction
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Administrator will have staff members tested for TB. Administrator will submit proof to CCL by 06/09/2023.
Type B
Section Cited
CCR
87412(d)
Personnel Records
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above as the Administrator does not have a currrent Administrator Certificare which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2023
Plan of Correction
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Administrator will complete the required training and submit documentation for recertification and submit proof of pending list for certification to CCL by 06/16/2023.
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 HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/23/2023 04:53 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: A COMPASSION VALLEY
FACILITY NUMBER: 195850143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 out of 6 resident did not have their Appraisal/Needs and Services completed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2023
Plan of Correction
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Administrator will reach out to residents representative and complete the Needs and Services. Administrator will submit proof to CCl by 06/16/2023.
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as 4 out of 6 residents did not have their Admission Agreement signed and dated by representative which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2023
Plan of Correction
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Administrator will reach out to residents representative and complete the Admission Agreement Form. Administrator will submit proof to CCl by 06/16/2023.
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 HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2023
LIC809 (FAS) - (06/04)
Page: 5 of 18


Document Has Been Signed on 05/23/2023 04:53 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: A COMPASSION VALLEY
FACILITY NUMBER: 195850143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as 6 out of 6 residents did not have PRN Authorization Form which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2023
Plan of Correction
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Administrator will send the PRN Authorization Form to residents physician. Administrator will submit proof of signatures and letter to CCL by 06/16/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2023
LIC809 (FAS) - (06/04)
Page: 6 of 18


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: A COMPASSION VALLEY
FACILITY NUMBER: 195850143
VISIT DATE: 05/23/2023
NARRATIVE
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The supply of perishable and nonperishable food is adequate. There are no pesticides (poisons) or toxins
stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all
appeared functional. Trash cans had tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in a locked cabinet. No flies or other vermin were observed. Hot water in kitchen was measured at 115.5 degrees Fahrenheit.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and
good condition. At the time of the visit, common seating area and dining room furniture was
observed to be in good condition. Chairs were observed to be at least 6 (six) feet apart for social
distancing. The LPA observed the required postings in the common hallway. Fire extinguishers
were observed to be serviced within the last year. The facility smoke alarm system is hardwired and
operated normally at the time of visit. Medications were observed to be locked in a closet by the
kitchen and contained at least 30 days of worth of medication. The garage door was observed and contained
a locked cabinet for laundry supplies. The backyard has a covered outdoor area equipped with furniture for
client use. There were no bodies of water noted.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Staff regarding the facility’s infection
control practices. Upon entry, the facility had a central entry point for symptom screening, temperature
checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment
(PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is
sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a
confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time. The facility’s policies and procedures as it pertains to infection control are adequate.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Starting at 12:12 p.m., during resident file review, four (4) out of six (6) residents did not have their Needs and Service Plan signed by the residents responsible party.

Continued on LIC 809 - C
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023
LIC809 (FAS) - (06/04)
Page: 17 of 18
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: A COMPASSION VALLEY
FACILITY NUMBER: 195850143
VISIT DATE: 05/23/2023
NARRATIVE
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At 12:15 p.m., during resident review, 4 out of 6 resident did not have their Admission Agreement signed by representative.
At 12:57 p.m., during staff file review, all staff members did not have 1st Aid/CPR Certification.
At 01:06 p.m., during staff file review, 1 staff member did not have their personnel file.
At 01:10 p.m., during staff file review, 4 out of 5 staff members did not have their Tuberculosis Test on file.
At 10:30 a.m., and 01:15 p.m., LPA observed expired Administrator Certificate. When questioned, Staff stated that Administrator began their initial training for re-certification but did not continue. LPA reviewed the Active and Pending Administrator Certificates on the CCLD website and did not observe Administrator name.
At 02:00 p.m., during medication review, 6 out of 6 residents did not have the PRN Authorization Form.
At 2:16 p.m., during medication review, R1 did not have medication at the facility.

Exit interview conducted and copy of the report and appeal right were issued.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023
LIC809 (FAS) - (06/04)
Page: 18 of 18