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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850163
Report Date: 08/24/2021
Date Signed: 08/24/2021 03:14:50 PM

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:BELLAIRE SENIOR CARE, LLCFACILITY NUMBER:
195850163
ADMINISTRATOR:HAKOBYAN, DAVITFACILITY TYPE:
740
ADDRESS:6523 BALLAIRE AVETELEPHONE:
(818) 516-8819
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY:6CENSUS: 6DATE:
08/24/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Davit HakobyanTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Ashley Smith and Salia Walker conducted an unannounced Case Management-Deficiencies inspection visit at the facility today due to deficiencies observed during the investigation of complaint control # 29-AS-20210816113039.

At 8:56 a.m., the LPAs observed that the gate was not single latched. When the staff allowed the LPAs on to the property, staff had to unlock the gate from the inside. This is a fire clearance violation. The LPAs informed the owner of this, and they stated that they would change the mechanism of the lock to ensure that it was single-latch only. The Licensee changed this mechanism and the LPAs observed the new lock at 2:50 p.m.

At 9:11 a.m., the LPAs identified there was only one staff to six residents. The staff claimed that they were only a volunteer. The LPAs confirmed that this individual was not associated to this facility. At 9:30 a.m., an additional caregiver Oganes “John” Duymalyan (S2) arrived, and stated that they have worked at the facility for almost six months. The LPAs confirmed that this individual was not associated to this facility. The Licensee previously attempted to associate S2 to the facility, but used an incorrect licensing number. During today's visit, the Licensee submitted the appropriate documentation to complete the clearance transfers.



At 10:33 a.m., the LPAs observed the medication cabinet to be open and accessible. The LPAs informed the Licensee, and the Licensee confirmed that they would repair the mechanism to ensure that medications remain locked and inaccessible. This was repaired during today's visit.

During today's visit, it was communicated that Resident #1 (R1) was hospitalized in August 2021. An incident report was not submitted to the Department, notifying the Department of the incident.

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. Civil penalties issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
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 3
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: BELLAIRE SENIOR CARE, LLC
FACILITY NUMBER: 195850163
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/24/2021
Section Cited

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87203 Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
This requirement is not met as evidenced by:
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Based on observation, the licensee did not comply with the section cited above, as the entrance gate was locked from the inside of the property to the facility grounds which poses an immediate health and safety risk to residents in care.

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Type A
08/24/2021
Section Cited

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87355(e)(2) 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: (2) Request a transfer of a criminal record clearance…
This requirement is not met as evidenced by:
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Based on interviews and observations, the licensee did not comply with the section cited above, as two individuals (S1, S2) have been working at the facility without a criminal record transfer, which poses an immediate safety 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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: BELLAIRE SENIOR CARE, LLC
FACILITY NUMBER: 195850163
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/25/2021
Section Cited

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87465(h)(2) Incidental Medical and Dental Care. The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees...
This requirement is not met as evidenced by:
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Based on observation, the licensee did not comply with the section cited above, as the medications were accessible during today’s visit, which poses an immediate health and safety risk to residents in care.
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Type B
08/27/2021
Section Cited

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87211(a)(1)(D) Reporting Requirements. A written report shall be submitted to the licensing agency ... within seven days of the occurrence: Any incident which threatens the welfare, safety or health of any resident.
This requirement is not met as evidenced by:
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Based on interview, the licensee did not comply with the section cited above, as an incident report was not submitted for R1's hospitalization, which poses a potential health and safety 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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3