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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850194
Report Date: 12/20/2024
Date Signed: 12/20/2024 04:12:53 PM

Document Has Been Signed on 12/20/2024 04:12 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/
DIRECTOR:		HAYRAPETYAN, ANNAFACILITY TYPE:
740
ADDRESS:7356 LEESCOTT AVE.TELEPHONE:
(818) 578-8589
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY: 6CENSUS: 6DATE:
12/20/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:10 PM
MET WITH:Gaiane Egizarian - CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Brian Balisi conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20230804102833). The purpose of the visit is to issue citations for deficiencies observed during the initial complaint investigation unrelated to the complaint. During today’s visit, LPA met with staff and explained the reason for the visit.

During the course of the investigation, facility administrator and staff, all denied that Resident #1 (R1) was ever a resident at the facility. Administrator and two staff members were also shown photos of R1, but they stated they did not recognize the person in the photos. On 11/05/2024, LPA obtained evidence to support that R1’s family paid R1’s monthly services via Zelle to Staff #1 (S1). On 12/20/2024, Licensing Program Manager (LPM) Desaree Perera conducted interviews with facility administrator and staff #1 (S1) approx. between 11:45 a.m. and 11:50 a.m. Interviews with administrator reflected that she did not recall who R1 was even though administrator stated she visited the facility daily. Administrator stated that she needed to review documents and speak to staff prior to responding to LPM. During the interview with S1, S1 initially stated that R1 did not reside at the facility however, when questioned why the family paid for services via Zelle for an individual that did not reside at the facility; S1 then stated she was confused and remembered there was two (2) individuals with the same name that used to reside prior. S1 also admitted to remembering this information after initial interview with LPA but failed to contact the LPA and provide the information. Records review also revealed that when S1 spoke to Home Health Nurse they presented themselves to the nurses as the Administrator of the facility. At approx 2:55pm LPA's records review revealed that there was no active or pending Administrator certificate on file for S1. LPM/LPA informed the facility administrator and staff the importance of providing truthful and accurate information at all times. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) S1 was informed that failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2024
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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Document Has Been Signed on 12/20/2024 04:12 PM - It Cannot Be Edited


Created By: Brian Balisi On 12/20/2024 at 03:14 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: 12/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/23/2024
Section Cited
CCR
87207

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87207 False Claims. No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met as evidenced by:
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Licensee agreed to review section cited and provide a statement of understanding to LPA via email by COB 12/23/204.
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Based on interviews and records review the licensee did not comply with the reg cited above as S1 presented themselves as Administrator to home health staff, which posed an immediate health, safety and / or personal rights risk to residents 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: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2024


LIC809 (FAS) - (06/04)
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