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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850194
Report Date: 09/20/2024
Date Signed: 09/20/2024 03:26:16 PM

Document Has Been Signed on 09/20/2024 03:26 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:DEPENDABLE OVERNIGHT CARE, INC.FACILITY NUMBER:
195850194
ADMINISTRATOR/
DIRECTOR:		HAYRAPETYAN, ANNAFACILITY TYPE:
740
ADDRESS:7356 LEESCOTT AVE.TELEPHONE:
(818) 578-8589
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY: 6CENSUS: 6DATE:
09/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:ANNA HAYRAPETYAN ; GAIANE EGIAZARIANTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
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Licensing Program Analysts (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 9:30 a.m. Upon arrival, LPA Mosley was greeted by staff and called the administrator to inform them of the visit. The administrator and CO-Owner arrived shortly thereafter. The LPA met with Administrator Anna Hayrapetyan and Co-Owner GAIANE EGIAZARIAN and explained the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Facility is a single-story residence and consists of a total of four (4) resident bedrooms, one (1) locked, inaccessible to residents’ staff room, three (3) resident bathrooms and one (1) locked, inaccessible staff bathroom. Fire clearance was approved on 7/20/2021 for four (4) non-ambulatory residents, one (1) ambulatory and one (1) bedridden. During physical plant tour LPA observed the required postings throughout the facility. At approximately. 9:35 a.m., LPA observed all six (6) residents mingling together at the dining room table looking through magazines and socializing.

RESTROOMS: The three (3) resident restrooms were clean and sanitary and in operable condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in all three (3) resident restrooms; the first restroom measured at 107.8 degrees Fahrenheit at 10:15 a.m. the second bathroom measured at 114.4 degrees Fahrenheit at 10:20 a.m., and the third restroom 106.3 at 10:31 a.m. All restrooms within the required range.

Report Continued on LIC 809C...

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: DEPENDABLE OVERNIGHT CARE, INC.
FACILITY NUMBER: 195850194
VISIT DATE: 09/20/2024
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Report Continued from LIC 809...

BEDROOMS: There are 4 (four) total bedrooms in the facility; two (2) are designated as a shared room, two (2) are designated as private resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

KITCHEN: The LPA inspected the kitchen/food service area at 10:22 a.m. Knives and sharps were observed in a locked cabinet. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 108.9 degrees Fahrenheit at 10:28 a.m. There is a washer and dryer on premises. Laundry detergent was observed in the locked laundry room/ staff bathroom.

COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 2:30 p.m., smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 09/03/2024. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 06/24/2024. Activities were observed in the common areas. Cameras were observed in common areas during the time of the visit.

GARAGE/BACKYARD: The garage is maintained locked at all times. LPA observed an adequate amount of emergency food and water. Cleaning supplies are kept in the garage locked and inaccessible to residents in care. There is a locked shed on the side of the home containing extra cleaning supplies. The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. LPA observed one (1) self-latching gate. There were no bodies of water noted at the time of the visit.



All exits in the facility have functioning auditory devices and were operational at the time of the visit.

Report Continued on LIC 809C...

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: DEPENDABLE OVERNIGHT CARE, INC.
FACILITY NUMBER: 195850194
VISIT DATE: 09/20/2024
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Report Continued from LIC 809...

MEDICATIONS: Medications review began at approximately 12:13 p.m. The medications are in locked medication cart in the living room area. Medications for four (4) clients were reviewed. Medications reviewed were found to be self administered as prescribed; however, documentation on the centrally stored medication and destruction record was not accurately documented which poses a potential health and safety risk to persons in care.

RECORDS: Resident Records were reviewed at approximately 10:40 a.m. and personnel records at approximately 11:30 a.m. Six (6) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. Five (5) personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order.

INTERVIEWS: Two (2) staff interviews were conducted. Due to language barriers a translation application was used to conduct interviews. No concerns were noted. Six (6) resident interviews were attempted. Due to language barriers two (2) interviews were conducted. No concerns were noted.

LPA obtained the following documents – LIC 500, LIC 9020, and current liability insurance.



The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, appeal rights discussed, and a copy of the report provided.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/20/2024 03:26 PM - It Cannot Be Edited


Created By: Erica Mosley On 09/20/2024 at 02:53 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: DEPENDABLE OVERNIGHT CARE, INC.
FACILITY NUMBER: 195850194

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and medication review, the licensee did not comply with the section cited above in four (4) out of six (6) residents centrally stored medication record did not match the prescription numbers which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2024
Plan of Correction
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Administrator will send proof of an updated centrally stored medication log with the correct RX numbers.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kasandra Lopez
LICENSING EVALUATOR NAME:Erica Mosley
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024


LIC809 (FAS) - (06/04)
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