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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850194
Report Date: 08/10/2023
Date Signed: 08/10/2023 12:47:31 PM

Document Has Been Signed on 08/10/2023 12:47 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:DEPENDABLE OVERNIGHT CARE, INC.FACILITY NUMBER:
195850194
ADMINISTRATOR:HAYRAPETYAN, ANNAFACILITY TYPE:
740
ADDRESS:7356 LEESCOTT AVE.TELEPHONE:
(818) 578-8589
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY: 6CENSUS: 6DATE:
08/10/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Gaiane Egizarian - Assistant AdministratorTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint control # 29-AS-20230804102833). LPA met with Assistant Administrator Gaiane Egizarian. The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint.

File review prior to visit indicated that room #3 is cleared for Ambulatory residents only. During the complaint visit, LPA conducted physical plant at approximately 9:15am, LPA observed Resident #1(R1) laying in bed in room #3.  Resident records review at approximately 10:15am, revealed that R1 is listed as Non-Ambulatory. Assistant Administrator was  advised to relocate resident to a room that has approved fire clearance for resident use.

A $500 immediate civil penalty is assessed today.  The Assistant Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f).

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):
Exit interview conducted/Citations issued/ Appeal Rights Discussed/ Copy of this report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2023
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 08/10/2023 12:47 PM - It Cannot Be Edited


Created By: Brian Balisi On 08/10/2023 at 12:09 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: 08/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/11/2023
Section Cited
CCR
87202(a)

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87202 (a) All facilities shall maintain a fire clearance approved by the city... county fire department, or district providing fire protection services, or the State Fire Marshal.

This requirement was not met as evidenced by:
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Within 24 hours, the Administrator agreed to relocate R1 to a room that has proper fire clearance. Administrator also agreed to submit proof of understanding and submit to LPA via email by EOD 08/11/2023. This is a zero tolerance violation, resulting in a civil penalty in the amount of $500.
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Based on LPA observation and record review, the licensee did not comply with the section cited above, as R1 who is listed as non-ambulatory, is residing in Room #3, that is cleared for ambulatory only, which poses an immediate health and safety risk to persons in care.
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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:Desaree Perera
LICENSING EVALUATOR NAME:Brian Balisi
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023


LIC809 (FAS) - (06/04)
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