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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850163
Report Date: 12/01/2021
Date Signed: 12/01/2021 05:14:11 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:
12/01/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Sandy Khambekyan, AdministratorTIME COMPLETED:
05:10 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 deficiencies observed during the investigation of complaint control # 29-AS-20211124110542.
At 12:09 p.m., the LPA observed two (2) medication boxes on top of the facility dining room table accessible to residents in care. The LPA informed staff #1 (S1) who was in the kitchen prepare meals, and S1 immediately locked and secured the medication. The LPA informed the Administrator upon arrival, and the Administrator confirmed that they would ensure that medications remain locked and inaccessible. The LPA advised the administrator that the facility was previously cited for accessible medication on 08/24/2021 under regulation 87465(h)(2), and therefore the facility will be issued civil penalties for a repeat violation. The administrator acknowledged, and confirmed staff will be retrained on section 87465(h)(2).
At 1:47 p.m., it was communicated that Resident #1 (R1) has refused all medication for approximately two (2) weeks. An incident report was not submitted to the Department, notifying the Department of the incidents. The Administrator stated that R1’s Hospice agency was notified, and the Hospice Agency stated they would notify R1’s PCP. The LPA advised the administrator, written report shall be submitted to the licensing agency within seven days of any incident which threatens the welfare, safety or health of any resident. . The LPA also advised the administrator that the facility was previously cited failure to report on 08/24/2021 under regulation 87211(a)(1)(D), and therefore the facility will be issued civil penalties for a repeat violation. The administrator acknowledged, and stated that the facility will be notifying all incidents pertaining to residents in the future to CCLD.
Pursuant to Title 22 of the California Code of Regulations, deficiencies were cited (refer to LIC 809-D). Civil penalties assessed for the repeat violations. $100 will be assessed per day until the deficiencies are corrected. 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: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
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: 12/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/03/2021
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 there were two (2) medications accessible on the facility dining room table during today’s visit, which poses an immediate health and safety risk to residents in care.
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Type B
12/03/2021
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 interviews, the licensee did not comply with the section cited above, as an incident report was not submitted for R1's refusal of medication, 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: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2021
LIC809 (FAS) - (06/04)
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