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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850163
Report Date: 11/23/2021
Date Signed: 11/23/2021 01:02:04 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:KHAMBEKYAN, SANDYFACILITY TYPE:
740
ADDRESS:6523 BALLAIRE AVETELEPHONE:
(818) 856-6980
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY:6CENSUS: 6DATE:
11/23/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Sandy Khambekyan, AdministratorTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Salia Walker conducted an unannounced Case Management- Deficiencies inspection at the facility today due to deficiency observed during the subsequent complaint inspection of complaint control #29-AS-20210816113039. The LPA met with administrator Sandy Khambekyan at 9:41 a.m., and explained the reason for the inspection.

At 8:55 a.m., the LPA observed one (1) bed, and three (3) personal storage space/dressers. The bed had a mattress, and was completed with full linens. The personal storage space/dressers contained clothes, shoes, and other personal items. The LPA inquired regarding the bed in the facility living room, and the personal storage space/dressers. The administrator, and Staff #1 (S1) confirmed that S1 was sleeping on the bed in the living room, and the items in the personal storage space/dressers belong to S1. The administrator acknowledged the living room may not be utilized in place of a staff room. The administrator stated that the bed, and personal storage space/dressers will be removed from the facility living room.



Pursuant to Title 22 of the California Code of Regulations, deficiency was cited (refer to LIC 809-D).
Exit interview conducted, and appeal rights discussed. A copy of the report and appeal rights were issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
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: BELLAIRE SENIOR CARE, LLC
FACILITY NUMBER: 195850163
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/29/2021
Section Cited

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87307(a)Personal Accommodations and Services (a)Living accommodations and grounds.. facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff..who may reside in the facility..
This requirement is not met as evidenced by:
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Based on Observation, and interviews, the licensee did not comply with the section cited above, as there was one (1) bed, and three (3) personal storage space/dressers in the facility living room S1 is utilizing, which poses a potential health, safety, and personal rights 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: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:
DATE: 11/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/23/2021
LIC809 (FAS) - (06/04)
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