195850146-4-13-2023-29-AS-AASO-CQV2F8-20230413172106

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850146
Report Date: 04/13/2023
Date Signed: 04/13/2023 05:31:57 PM

Document Has Been Signed on 04/13/2023 05:31 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:	MY HOME OF AGING		FACILITY NUMBER:	195850146
ADMINISTRATOR:	KYKHOSROWPOUR, VISHTASB		FACILITY TYPE:	740
ADDRESS:	23817 BESSEMER STREET		TELEPHONE:	(818) 433-4592
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 6	DATE:	04/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Vishtasb Kykhosrowpour		TIME COMPLETED:	05:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Angel Ascencio and Zabel Chochain arrived at the facility unannounced to conduct a required Annual visit. The LPAs met with Administrator Vishtasb Kykhosrowpour and Farnaz Servati and explained the reason for the visit. The LPA toured the physical plant areas inside and outside, with Vishtasb Kykhosrowpour at 9:15 a.m., to ensure there are no health and safety hazards. BEDROOMS: There are (6) six bedrooms designated for resident use. Bedroom #1 has a direct exit to the exterior. The facility is capable of furnishing each room with clean linens, appropriate furnishings, and sufficient lighting for resident use. RESTROOMS: There are (4) four bathrooms designated for resident use. (2) two bathrooms are located inside the resident bedrooms and (2) two are located in the hallway. Bathrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPAs measured the hot water temperature in (2) two out (4) four bathrooms. The hot water temperatures measured between 110.6 and 115.9 degrees Fahrenheit. KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be properly stored and locked at time of visit. Hot water was measured and was within regulation. Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 5

Document Has Been Signed on 04/13/2023 05:31 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: MY HOME OF AGING	FACILITY NUMBER: 195850146
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

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:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as ibuprofen and anti-itch cream was observed to be accesible in the common area which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2023
	Plan of Correction
1 2 3 4	Administrator secured items during tour. Administrator will conduct staff training on Section 87705 (f)(2) and submit to CCL by 4/19/2023.

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	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 04/13/2023 05:31 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: MY HOME OF AGING	FACILITY NUMBER: 195850146
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/13/2023

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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in six (6) out of 6 residents did not have a PRN Authorization form to determine his/her own needs which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/28/2023
	Plan of Correction
1 2 3 4	Administrator will send PRN Authorization form to Primary Physician for signatures. Administrator will submit 6 PRN Authorization form to CCL by 4/28/2023.

Type B

Section Cited

CCR

87608(a)(5)(B)

Postural Supports

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, the licensee did not comply with the section cited above as three (3) out of 6 residents were observed to have full bed rails while not on hospice services, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/28/2023
	Plan of Correction
1 2 3 4	Administrator removed the full rails during visit.

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	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 04/13/2023 05:31 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: MY HOME OF AGING	FACILITY NUMBER: 195850146
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307

87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: 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 as a section of the common living area was used as a staff sleeping area which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/28/2023
	Plan of Correction
1 2 3 4	Administrator removed curtain barrier, bed and night stand from common area. Administrator will provide updated staff schedule to reflect 24 hour care services due to not having a designated staff room.

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	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

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: MY HOME OF AGING	FACILITY NUMBER: 195850146
	VISIT DATE: 04/13/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

COMMON SPACES: The common spaces included the living room; dining area and office area. The LPAs observed cameras in all common spaces and exterior. All areas were clean, sanitary and in good repair. Smoke detectors are hardwired and interconnected, there is a Carbon Monoxide detector installed at the facility. The fire extinguisher was observed to be in compliance within one year. The LPAs observed required postings in the entrance hallway.

BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. There is a pool on the property that was observed to be gated and locked at the time of the visit. The LPAs observed a Laundry room which is located inside the attached garage. Laundry detergents, cleaning supplies, pesticides, and/or toxins are also stored in the garage/laundry area.

INFECTION CONTROL: During today’s visit, the LPAs spoke with the Administrator Vishtasb Kykhosrowpour regarding the facility’s infection control practices. The LPAs advised the Administrator to maintain a 30-day supply of Personal Protection Equipment (PPE). 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 and the LPAs reviewed facility’s policies and procedures as it pertains to infection control.

During today's visit, the following deficiencies were observed and cited under LIC 809 - D:

At 9:45 a.m. Full bed rails were observed for three (3) out of 6 residents that were not on hospice.
At 9:52 a.m. Ibuprofen and Anti-Itch cream was observed accessible in the common area.
At 9:55 a.m. A section of the common living area was set up as a staff sleeping area.
At 2:30 p.m. Six (6) out of 6 resident did not have PRN Authorization Forms.

Exit interview conducted and a copy of the report and appeal rights were issued to Administrator.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

LIC809 (FAS) - (06/04)

Page: 5 of 5