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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850176
Report Date: 11/18/2024
Date Signed: 11/18/2024 05:30:44 PM

Document Has Been Signed on 11/18/2024 05:30 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:NOHO ASSISTED LIVING, INCFACILITY NUMBER:
195850176
ADMINISTRATOR/
DIRECTOR:		ARPINE MKRTCHYANFACILITY TYPE:
740
ADDRESS:6331 SIMPSON AVETELEPHONE:
(818) 404-0550
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 6CENSUS: 4DATE:
11/18/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:28 PM
MET WITH:Arpine Mkrtchyan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:40 PM
NARRATIVE
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Licensing Program Analyst(LPA) Christine Yee conducted an unannounced case management visit due to the deficiencies noted during a visit to the facility today.

The following was observed during today's visit:
  • Hospice services were initiated for Resident #1 on 11/8/24 and it was not reported to the Department within 5 days as required
  • Oxygen is in use by Resident #1 and the Licensee did not report it in writing to the fire department.

The incident and hospitalization of Resident #1 was also not reported to the Department but they have till the end of today to file the incident report.

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


Exit interview was conducted, Appeals Rights discussed and a copy was given.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
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 11/18/2024 05:30 PM - It Cannot Be Edited


Created By: Christine Yee On 11/18/2024 at 04:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: NOHO ASSISTED LIVING, INC
FACILITY NUMBER: 195850176

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/25/2024
Section Cited
CCR
87618(b)(3)(A)

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Oxygen Administration - Gas and Liquid: In addition to Section 87611(b), the licensee shall be responsible for the following: Ensuring that the use of oxygen equipment meets the following requirements: A report shall be made in writing to the local fire jurisdiction that
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Licensee will submit written notification to the local fire department of oxygen being used at the facility. A copy of the notification letter will be provided to the Department as evidence that the local fire department was notified by 11/25/24.
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oxygen is in use at the facility. This requirement was not as evidenced by: Resident #1 uses oxygen and it was not reported to the local fire department as of today's visit
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Type B
11/25/2024
Section Cited
CCR87632(d)(2)

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Hospice Care Waiver: If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver as necessary to ensure the well-being of terminally ill residents and of all other facility residents, which shall include, but not be limited to, the following requirements:
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Licensee will submit an hospice initiation letter to the Department for all residents who are placed on hospice within 5 days of initiation. Licensee will submit a hospice initiation letter with the name of the resident, date of initiation, name of the hospice agency and address and telephone number by 11/25/24
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The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice. Resident #1 was receiving hospice services begining 11/8/24 and it was not reported to the Department
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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:Kristin Heffernan
LICENSING EVALUATOR NAME:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2024


LIC809 (FAS) - (06/04)
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