<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850176
Report Date: 08/22/2023
Date Signed: 08/22/2023 06:14:22 PM


Document Has Been Signed on 08/22/2023 06:14 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:NOHO ASSISTED LIVING, INCFACILITY NUMBER:
195850176
ADMINISTRATOR:ARPINE MKRTCHYANFACILITY TYPE:
740
ADDRESS:6331 SIMPSON AVETELEPHONE:
(818) 404-0550
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY:6CENSUS: 5DATE:
08/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Arpine Mkrtchyan AdministratorTIME COMPLETED:
06:20 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) Christine Yee conducted an unannounced required Annual Inspection visit and utilized the complete CARE Inspection Tool. LPA Yee was given entry into the home by Anahit Anatomyan, Staff. Staff contacted Arpine Mkrtchyan, Administrator, via telephone and she arrived at 10:03am to conduct the visit. LPA Yee explained the reason for today's visit.

The facility is a single storey family home consisting of a living room, dining room, a kitchen, 3 resident bedrooms, 2.5 bathrooms, a den, a laundry room and a attached garage. The facility is fire cleared for 6 non-ambulatory residents.
The following was observed on today's visit:
  • The dining room and living room have the appropriate furniture for 6 residents and was clean
  • The fire place was observed without a metal fire screen
  • The kitchen has the standard equipment - stove, refrigerator, toaster oven, coffee maker and dishwasher and was observed to be operational and clean. Knives are stored in a locked drawer.
  • sufficient perishable and non-perishable foods were observed in the kitchen and in the garage
  • Bedroom #1 and Bedroom #2 contained 2 hospital beds, 2 chairs, 2 lamps, no dressers, a shared closet and blinds for privacy. No window bars were observed.
  • Bedroom #3 is a private bedroom and was furnished with the resident's personal furniture
  • Appropriate bed linens were observed on residents' beds. Extra bed linens were observed in the linen closet.
  • Bedroom #1 has a private bathroom and was observed with a shower, a shower chair, grab bars and non-skid mat.
  • The two common bathrooms were toured. The common bathroom located by bedroom #1 has a toilet and sink. Water temperature was tested and read 117.8 degrees Fahrenheit.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023
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 5


Document Has Been Signed on 08/22/2023 06:14 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: NOHO ASSISTED LIVING, INC
FACILITY NUMBER: 195850176

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(7)
Personal Accommodations and Services
(7) Fireplaces and open-faced heaters shall be adequately screened.

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 as the fire place was observed with a sliding glass door and did not have a fire screen placed in front to make the fire place inaccessible to the residents in care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2023
Plan of Correction
1
2
3
4
The Licensee will purchase a fire screen and place in front of the fire place so that there is no direct access to the fire place by 8/29/23
Type B
Section Cited
CCR
87465(d)(1)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (1) Facility staff shall contact the resident's physician prior to each dose, describe the resident's symptoms, and receive direction to assist the resident in self-administration of that dose of medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 4 out of 5 files reviewed, the facility has not obtained PRN Authorization letters for Resident # 1, Resident #2, Resident #4 and Resident #5 to determine if the residents are capable of making their need for the medications known. The facility has been dispensing medications without contacting the physician and obtaining instructions and this poses a potential health, safety risk or personal rights risk to persons in care.
POC Due Date: 08/29/2023
Plan of Correction
1
2
3
4
The Licensee will contact the prescribing physicians to obtain completed PRN Authorization letters for Residents #1, #2, #4 and #5 and maintain in the residents files. A copy will also be faxed over to Licensing by 8/9/23.
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 PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 08/22/2023 06:14 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: NOHO ASSISTED LIVING, INC
FACILITY NUMBER: 195850176

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)(2)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) The date and time of each contact with the physician, and the physician's directions, shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 4 out of 5 files reviewed that the staff are dispensing PRN medications without contacting the doctor and are not documenting the physicians instructions, the results of the the medication, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2023
Plan of Correction
1
2
3
4
The Licensee will in addition to documenting the date and dosage that the PRN medication was dispensed, also include the results of the medication
Type B
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review the licensee did not comply with the section cited above in 4 out of 5 counts by not documenting the residents results of the medication which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2023
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 PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 08/22/2023 06:14 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: NOHO ASSISTED LIVING, INC
FACILITY NUMBER: 195850176

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(e)(1-2)
Incidental Medical and Dental Care:(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.(1) The specific symptoms which indicate the need for the use of the medication.(2) The exact dosage.(3) The minimum number of hours between doses.(4) The maximum number of doses allowed in each 24-hour period.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 5 out of 5 counts of files reviewed for physician's orders for the centrally stored medications. None of the files had copies of physicians orders on file for the centrally stored medication which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2023
Plan of Correction
1
2
3
4
The Liicensee will contact the prescribing doctor for all centrally stored medications and obtain a copy of the doctor's written order on a prescription blank and maintain in the resident's file
Type B
Section Cited
CCR
87307(3)(B)
87307 Personal Accommodations and Services. (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of:
(B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers

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 out of 3 resident bedrooms toured, bedroom #1 and bedroom #2 did not have any chest of drawers which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2023
Plan of Correction
1
2
3
4
The Licensee will purchase chest of drawers that meet Titlee22 requirement for bedroom #1 and bedroom #2 . Provide evidence that the chest of drawers have been purchased by 8/29/23
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 PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023
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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: NOHO ASSISTED LIVING, INC
FACILITY NUMBER: 195850176
VISIT DATE: 08/22/2023
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
26
27
28
29
30
31
32
  • The common bathroom located by the laundry room has a bath tub with a shower. Grab bars and a non-skid mat was observed. Water temperature was tested and read 117.9 i degrees Fahrenheit
  • The facility has a fire extinguisher purchased on 3/22/23 and is located in the kitchen
  • A first aid kit and first aid manual was observed in the kitchen.
  • Medications are centrally stored in a cabinet located in the kitchen
  • Staff have current first aid training.
  • Administrator has a current certificate - expires on 10/13/23. CEUs were submitted for renewal.
  • The hardwired smoke detectors were tested and were operational
  • Disinfectants, cleaning solutions and laundry detergents are stored in the locked laundry room.
  • A tour of the outside was conducted and a table with four chairs and a umbrella was observed in the backyard. The front yard was observed to be clean and well maintained.
  • There were no bodies of water observed.
  • Auditory devices were observed on the front door and on the sliding glass door in the den. .
  • Trash cans stored in the front yard were observed tightly sealed.
  • The facility has a Infection Control Plan, Plan of Operation and an Emergency Disaster Plan on the premises



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

Exit interview was conducted, APPEALS RIGHTS were discussed and a copy was provided.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5