195850163-7-13-2023-29-AS-CYEE-CTQ2V4-20230713174319

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850163
Report Date: 07/13/2023
Date Signed: 07/13/2023 05:43:33 PM

Document Has Been Signed on 07/13/2023 05:43 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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BELLAIRE SENIOR CARE, LLC		FACILITY NUMBER:	195850163
ADMINISTRATOR:	ELEN KIRAKOSYAN		FACILITY TYPE:	740
ADDRESS:	6523 BALLAIRE AVE		TELEPHONE:	(818) 856-6980
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY:	6	CENSUS: 6	DATE:	07/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:02 AM
MET WITH:	Ovsanna Khayalyan, House Manager		TIME COMPLETED:	06:00 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 Analyst(LPA) Christine Yee conducted an unannounced required Annual Inspection and was let into the home by Venera Nesterova, Staff. Ovsanna Khayalyan, House Manager was contacted by staff via telelphone and she arrived at 10:41am to conduct the visit. Ellen Kirakosyan, was not available to conduct the visit. The reason for today's visit was explained. The facility is a single storey home consisting of a living room, dining room, kitchen, 3 bedrooms, 2 full bathrooms and a car port. The facility is fire cleared for 5 non-ambulatory and 1 bedridden resident in bedroom #1 only. Located on the same property is another building that is rented out. Today's annual inspection was conducted using the complete CARE Inspection Tool during this visit. The following were observed on today visit: the living room was observed with the appropriate seating for the resident capacity the dining room was observed with a table and 6 chairs the kitchen was observed with a refrigerator and stove. Both were operational sufficient perishables and non-perishable foods were observed medications are stored in a kitchen cupboard sharp knives are stored in a locked kitchen drawer cleaning solutions are stored in the locked cabinet under the kitchen sink the only fire extinguisher purchased in May 2023 is located on a kitchen shelf Bedroom #1(end of the hallway) contains 2 hospital beds with bed rails mounted on in the middle of both sides of the bed. There were no chairs, only 1 dresser, 2 lamps, 1 closet. Located in the room is a portable closet used to store the facility linens. Located inside the room is a full private bathroom. Shower chairs and grab bars were observed. No non-skid mats were observed. The water temperature Continued on LIC809-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELLAIRE SENIOR CARE, LLC	FACILITY NUMBER: 195850163
	VISIT DATE: 07/13/2023

NARRATIVE

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was tested and it read 111.20 degrees Fahrenheit
Staff have current first aid card
a tour of the front and backyard was conducted and it was observed that the front and backyard needs general cleaning, discard unused boxes, wires, hoses, plastic bins, wooden boards, plastic bottles or store unused wheel chairs.
Per file review and interview, the facility has retained 6 residents on hospice and have been approved for 4 only

Due to time constraints, the Annual Inspection will be continued on a return visit

Deficiencies cited under California Code of Regulations, Title 22, Division 6 Chapter 8. Any deficiencies not cited on today's visit will be addressed on a return visit.

Exit interview was conducted, APPEALS RIGHTS discussed and a copy was provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/13/2023 05:43 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELLAIRE SENIOR CARE, LLC	FACILITY NUMBER: 195850163
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/13/2023

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 2 of 2 counts the facility failed to provide non-skid mats in the common bathroom and private bathroom which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/20/2023
	Plan of Correction
1 2 3 4	The Licensee will purchase non-skid mats for the common and private bathroom and provide evidence such as a copy of the receipt to licensing by 7/20/23

Type B

Section Cited

CCR

87307

Personal Accommodations and Services: Living accommodations and grounds shall be related to the facility's function....The following provisions shall apply: (B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading The following provisions shall apply:, and a chest of drawers This requirement is not met as evidenced by: Per tour of the resident bedrooms, Bedroom #1 has one dresser, no chairs, Berrom #2 and # 3 does not have any chairs or dressers
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 5 out of 6 counts. There was only one dresser observed in Bedroom #1, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/27/2023
	Plan of Correction
1 2 3 4	The Licensee shall read section 87307 Personal Accomodations and Services and provide the residents with the required furniture. 6 Chairs, 5 Dressers meeting statutory requirements. Provide a copy of the receipt to Licensing by 7/27/23

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 Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 07/13/2023 05:43 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELLAIRE SENIOR CARE, LLC	FACILITY NUMBER: 195850163
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87632(a)

87632 Hospice Care Waiver: In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. To obtain this waiver the licensee shall submit a written request for a waiver to the Department on behalf of any residents who may request retention, and any future residents who may request acceptance, along with the provision of hospice services in the facility. This requirement is not met as evidenced by: Per review of records and interview with staff, the facility has retained 6 residents who receive hospice services. The facility is approved for 4 hospice waivers
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above in 6 out of 6 count, the facility has retained 2 additional residents on hospice, which has exceeded the 4 approved hospice waiver which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/20/2023
	Plan of Correction
1 2 3 4	Licensee will read Title 22, Section 87632 and submit a request for additional hospice waiver by POC date 7/20/23

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

LIC809 (FAS) - (06/04)

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