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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850143
Report Date: 07/29/2021
Date Signed: 07/29/2021 08:04:29 PM

Document Has Been Signed on 07/29/2021 08:04 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: 5DATE:
07/29/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:GAMLET KUYUMCHYANTIME COMPLETED:
08:15 PM
NARRATIVE
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At 9:30 am, Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced case management visit at the facility. Reason for visit was due to Mitigation Plan not being submitted.

The Licensee is currently not available to be at the facility. Licensee did not notify CCLD about a positive COVID case. LPA Peraldi spoke to Licensee over the phone and Licensee authorized GAMLET KUYUMCHYAN to sign the report. Licensee also designated GAMLET KUYUMCHYAN as the facility representative and he agreed to remain on site until Licensee returns or cleared staff are working at the facility.

LPA Peraldi was let in the facility by a resident. LPA Peraldi observed five (5) residents and two (2) individuals. The two (2) individuals were working as caregivers. The individuals refused to give identifying information. One (1) of the residents left the facility. LPA Peraldi had difficulty communicating with the individuals due to a language barrier. LPA Peraldi used Language Link to communicate with the individuals, reference number is: 209269. The two (2) individuals working as caregivers during today's visit, are not cleared to work at the facility.

Staff GAMLET KUYUMCHYAN arrived at the facility at 1:15pm. LPA Kelly Dulek arrived at the 1:20pm.

Between 9:45am and 4:30pm, LPAs toured the facility. At 9:43am, LPA Peraldi observed knives, scissors and medications in the kitchen which were accessible and not properly stored. Facility has approved fire clearance for two (2) ambulatory and four (4) non-ambulatory residents. Interview with staff revealed that Resident One (R1) and Resident Two (R2) are non-ambulatory and residing in room one (1) which has an ambulatory only fire clearance. Staff stated that the two individuals working as caregivers are residing in room four (4) and sharing a room with Resident Three (R3). LPA Peraldi observed two furnished beds in room 4.
Continued on LIC 809-C.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2021
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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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: 07/29/2021
NARRATIVE
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Continued from LIC 809.

At 2:20pm, LPAs observed disinfecting spray, over the counter medications and personal hygiene items in the restrooms. The entrance has a rug that does not have non slip material.

At 2:30pm, LPA Dulek reviewed medications and attempted to review resident and staff records. No resident records or staff files were available for review during today's visit. Medications were observed to be unlocked throughout the kitchen cabinets. LPA Dulek observed medications from individuals not currently residing at the facility. Resident Two’s (R2) medications were not stored in its originally received container and not labeled. No record of centrally stored medications for each resident were available.

The Licensee emailed the Mitigation Plan to CCLD during today’s visit.

Per California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited. An immediate civil penalty of $1500 is also assessed. The licensee was informed that a civil penalty might be assessed based on the Health and Safety Code 1569,49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).

Exit interview conducted/ Appeal rights provided/ A copy of this report will be emailed.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 07/29/2021 08:04 PM - It Cannot Be Edited


Created By: Emily Peraldi On 07/29/2021 at 05:13 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: 07/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/29/2021
Section Cited
CCR
87355(e)(1)

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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 or
This requirement is not met as evidenced by:
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Licensee agreed to only employ staff that have obtain criminal record clearance and are associated to the facility. Administrator understands that the two (2) individuals cannot be present at the facility until they have obtained criminal record clearance.
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Based on interviews and observations, two individuals have been working at the facility since 07/24/2021 and have no criminal record clearance, which poses an immediate safety risk to persons in care.
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By POC due date, all individuals not cleared or associated to the facility must be removed from the facility.
Type A
07/30/2021
Section Cited
CCR87202(a)

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87202 Fire Clearance. (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal...

This requirement is not met as evidenced by:
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Licensee agreed to move residents to the appropriate rooms according to the approved fire clearance and facility sketch by POC due date.
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Interview with staff revealed that Resident One (R1) and Resident Two (R2) are non-ambulatory and residing in room one (1) which has an ambulatory only fire clearance which poses an immediate 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:Kristin Heffernan
LICENSING EVALUATOR NAME:Emily Peraldi
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/29/2021 08:04 PM - It Cannot Be Edited


Created By: Emily Peraldi On 07/29/2021 at 05:56 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: 07/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/29/2021
Section Cited
CCR
87705(f)(1)

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87705 Care of Persons with Dementia: (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
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 During today’s visit, staff properly stored knives and scissors in locked kitchen cabinets making them inaccessible to residents. POC cleared.
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Based observation, knives, scissors and medications were accessible and not properly stored in kitchen drawers and cabinet which poses an immediate safety risk to persons in care.
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Type A
07/29/2021
Section Cited
CCR87705(f)(2)

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87705 Care of Persons with Dementia:(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
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During today's visit, staff agreed to lock up the above items. Licensee agreed to keep above items inaccessible to residents. POC cleared.
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Based on observation, disinfecting spray, over the counter medications and personal hygiene items were in restrooms which poses an immediate 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:Kristin Heffernan
LICENSING EVALUATOR NAME:Emily Peraldi
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/29/2021 08:04 PM - It Cannot Be Edited


Created By: Emily Peraldi On 07/29/2021 at 06:14 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: 07/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/30/2021
Section Cited
CCR
87465(h)(5)

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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container...

This requirement is not met as evidenced by:
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Licensee will contact residents responsible party to request properly labeled prescription bottles and will inform LPA by POC due date when bottles will be delivered. Licensee agreed to schedule vendorized training for all staff and inform LPA of vendor information and scheduled date by POC due date.
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Based on observation, Resident Two’s (R2) medications were not stored in its originally received container and is not labled which poses an immediate health risk to persons in care.
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Proof of completed training to be submitted to CCLD by 08/12/2021.
Type A
07/30/2021
Section Cited
CCR87465(h)(6)

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87465. Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes...
This requirement is not met as evidenced by:
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 Licensee agreed to schedule vendorized training for all staff and inform LPA of vendor information and scheduled date by POC due date.
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Based on observation, no record of centrally stored medications for each resident were available which poses an immediate health risk to persons in care.
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Proof of completed training to be submitted to CCLD by 08/12/2021.
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:Emily Peraldi
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2021


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 07/29/2021 08:04 PM - It Cannot Be Edited


Created By: Emily Peraldi On 07/29/2021 at 06:44 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: 07/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/29/2021
Section Cited
CCR
87468.2(a)(1)

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights...facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations...

This requirement is not met as evidenced by:
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Licensee agreed to remove the two individuals who share a room with R3 by POC due date.
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Based on staff interviews, the two individuals working as caregivers are residing in room four (4) and sharing a room with Resident Three (R3) which poses an immediate personal rights risk to persons in care.
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Type A
07/29/2021
Section Cited
CCR87211(a)(2)

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87211. Reporting Requirements: (a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (2)Occurrences, such as epidemic outbreaks...

This requirement is not met as evidenced by:
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On 07/29/2021, Licensee notified CCLD about epidemic outbreak and emailed CCLD the Mitigation Plan. POC cleared.
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Based on interviews, licensee did not notify CCLD of epidemic outbreak affecting the facility; based on observation and record review, the licensee did not submit the required COVID-19 Mitigation Plan Report to CCLD, which poses an immediate health risk to residents 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:Kristin Heffernan
LICENSING EVALUATOR NAME:Emily Peraldi
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2021


LIC809 (FAS) - (06/04)
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