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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850163
Report Date: 03/23/2023
Date Signed: 03/23/2023 03:42:22 PM


Document Has Been Signed on 03/23/2023 03:42 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, LLCFACILITY NUMBER:
195850163
ADMINISTRATOR:ELEN KIRAKOSYANFACILITY TYPE:
740
ADDRESS:6523 BALLAIRE AVETELEPHONE:
(818) 856-6980
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY:6CENSUS: 5DATE:
03/23/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Ovsanna Khayalyan, House ManagerTIME COMPLETED:
03:50 PM
NARRATIVE
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Licensing Program Analyst(LPA) Christine Yee conducted an unannounced case management visit due to deficiencies noted during a complaint visit to the facility today.
The visit was initially conducted with Ovsanna Khayalyan, House Manager but she had to leave and the remainder of the visit was conducted with Venera Nesterova, Staff.

A complaint was received by the Department regarding the elopement of a new resident within twenty to thirty minutes after arrival to the home. The facility failed to report this incident to the Department.


Deficiencies were cited under California Code of Regulations, Title 22, Division 6, Chapter 8.


Exit interview was conducted with Venera Nesterova, Appeals Rights discussed and a copy of report was provided.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023
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 2


Document Has Been Signed on 03/23/2023 03:42 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: 03/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/30/2023
Section Cited

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Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following (1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in
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The Licensee will review Title 22 Section 87211 and submit a signed written statement that the section was read and understood and the licensee will comply with the requirements. Submit POC by
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 (A) thru (D below. Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
Licensee failed to report Resident #1 eloped and was missing.
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3/30/23

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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: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023
LIC809 (FAS) - (06/04)
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