195850166-6-20-2023-29-AS-EPEI-CSYUXZ-20230620155910

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850166
Report Date: 06/20/2023
Date Signed: 06/20/2023 03:59:40 PM

Document Has Been Signed on 06/20/2023 03:59 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	AAA QUALITY RESIDENTIAL CARE FACILITY		FACILITY NUMBER:	195850166
ADMINISTRATOR:	KIRAKOSYAN, ELEN		FACILITY TYPE:	740
ADDRESS:	7843 STANSBURY AVE.		TELEPHONE:	(323) 485-4851
CITY:	PANORAMA CITY	STATE: CA	ZIP CODE:	91402
CAPACITY:	6	CENSUS: 2	DATE:	06/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Ovsanna Khayalyan, Licensee		TIME COMPLETED:	04:20 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) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 12:00 p.m., the LPA met with staff and explained the reason for it visit. At 12:27 p.m., the Licensee arrived at the facility. At 12:45 p.m., the LPA, along with the Licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. KITCHEN: The LPA observed the kitchen/dining area. Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 1:17 p.m., hot water measured at 106.3-degree Fahrenheit. Medications are located in a locked kitchen cabinet. However, at 12:48 p.m., the LPA observed medication accessible in the refrigerator. The Licensee explained that she will ensure that the medications will be locked and inaccessible. BEDROOMS: The facility is a single-story residential home with three (3) bedrooms and one (1) bathroom for resident's use. There is an additional bedroom for staff use, which remains locked. The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. At 12:52 p.m., the LPA observed Resident #1 (R1) residing in room three (3), which is not the identified bedridden room. Per R1’s physician’s report, R1 is identified as bedridden. Per the fire clearance, a bedridden resident can only reside in Bedroom #1. An immediate civil penalty of $500 is assessed, due to a violation of the fire clearance. Continued on LIC 809-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

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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Document Has Been Signed on 06/20/2023 03:59 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AAA QUALITY RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 195850166
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) 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 responsible for the supervision of the centrally stored medication. 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 above cited section, as medications were observed to be accessible inside the refrigerator, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 06/21/2023
	Plan of Correction
1 2 3 4	Licensee stated they will obtain a lock for the medications that are stored in the refrigerator and ensure all other medications remain locked. Proof of locked medications will be sent to CCL by POC due date.

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: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/20/2023 03:59 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AAA QUALITY RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 195850166
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)(2)

87202(a)(2) Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city... Prior to accepting or retaining any of the following types of persons... licensee shall notify the licensing agency...(2) Bedridden persons. 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, R1 is bedridden and does not reside in the bedridden room, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 06/21/2023
	Plan of Correction
1 2 3 4	The Licensee agreed to do the following: 1. Within 24 hours, the licensee will relocate R1 to the bedridden room. Proof to be submitted to CCL by 06/21/2023 - end of day. This is a zero-tolerance violation, resulting in a civil penalty in the amount of $500.

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: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

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: AAA QUALITY RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 195850166
	VISIT DATE: 06/20/2023

NARRATIVE

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RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. At 1:15 p.m., hot water 105.6-degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels. Signs are posted throughout the facility restrooms to promote handwashing. There is a washer and dryer located in the staff restroom. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in the staff restroom. The first aid kit observed in the staff restroom.

OUTDOOR SPACE: At 1:20 p.m., the LPA observed the back patio which has a covered outdoor area for resident use. There is a gate on the side of the house designated for an emergency exit. Passageways were free and clear from obstruction. There are no bodies of water on the premises.

COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished. The LPA observed the fire extinguisher to be fully charged and purchased on 05/21/2023. At 1:18 p.m., fire alarms/carbon monoxide detectors were tested and functioned properly. Night lights were present in the hallways and passages. All exits have functioning auditory devices and were operational at the time of the visit.

RECORD REVIEWS: Between 1:27 p.m. and 2:50 p.m., the LPA conducted a file review for all residents and staff regularly scheduled and observed the following: Staff have current first aid and training documentation showing required training completed. Resident records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All files were in order.

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8 and California Health and Safety Code the following deficiencies were cited (refer to LIC 809-D). Civil Penalties assessed in the amount of $500. Failure to correct the deficiencies may result in additional civil penalties

Due to time constraints the LPA will return to complete the annual at a later date.

Exit interview conducted. A copy of the report and and appeal rights were issued.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC809 (FAS) - (06/04)

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