195850216-2-8-2024-29-AS-SURA-D2A25M-20240208160546

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850216
Report Date: 02/08/2024
Date Signed: 02/08/2024 04:07:05 PM

Document Has Been Signed on 02/08/2024 04:07 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:	ELDERCARE HOMES, INC.		FACILITY NUMBER:	195850216
ADMINISTRATOR:	HEKIMYAN, LUIZA		FACILITY TYPE:	740
ADDRESS:	7754 COLDWATER CANYON AVENUE		TELEPHONE:	(818) 764-8545
CITY:	N. HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY:	6	CENSUS: 5	DATE:	02/08/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:09 AM
MET WITH:	Tina Arutyunyan		TIME COMPLETED:	04:10 PM

NARRATIVE

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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual inspection. LPA Urena arrived at 9:50 a.m. Staff greeted the LPA and contacted the facility representative Tina Arutyunyan via telephone. The facility representative arrived shortly thereafter.

LPA Urena, and staff 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.

KITCHEN: Kitchen knives are stored locked and inaccessible in a kitchen drawer. A seven-day supply of non- perishable foods was available. The supply of dishes is adequate. Appliances in the kitchen were clean and all appeared functional. Kitchen, laundry, and house cleaning supplies are stored, locked, and located in the laundry room which is adjacent to the kitchen.
COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature of 70 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. One fire extinguisher located by the kitchen area was purchased on 09/12/2023. The LPA observed required postings throughout the common space.

BEDROOMS: Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are three designated client rooms and one staff room. There was a linen closet in the hallway with extra towels and linens.

BATHROOMS: Bathrooms were clean, shower area was in clean condition with grab bars and a non-skid mat available. Paper towels were available for drying hands. Hand washing signs were displayed, and sufficient amounts of soap and paper products in each restroom. Continues on LIC 809C...

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

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: ELDERCARE HOMES, INC.	FACILITY NUMBER: 195850216
	VISIT DATE: 02/08/2024

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OUTDOOR SPACE/GARAGE: Backyard is equipped with furniture in good repair for residents’ use. There were no bodies of water noted. Side gate is unlocked, and passageways were clear of any obstructions. The garage is detached from the main house, and the door was locked at the time of the visit.

RECORDS: Records review began at 11:57 a.m.., Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 1:00 p.m. ; medications are centrally stored and locked in a cabinet in the kitchen area; medications are labeled and checked for expiration dates. During the medication review, it was observed that the medications were not properly documented on the centrally stored medications and destruction record (LIC 622) . Five out of five residents' LIC 622 were not filled out correctly, which were missing Start Date (first date of medication assistance), and refills.

INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

The LPA reviewed the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster

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.

Deficiencies were cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/08/2024 04:07 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELDERCARE HOMES, INC.	FACILITY NUMBER: 195850216
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/08/2024

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
1 2 3 4	Based on medication review, the licensee did not comply with the section cited above in five out of five LIC 622 forms were incorrectly filled out for five out of five residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/12/2024
	Plan of Correction
1 2 3 4	POC: Administrator will provide medication training for staff, specifically on how to fill out the LIC 622 correctly. Administrator will submit a copy of the training sign in sheet with signatures, date and hours of training, training material, and credential of the professonal providing the training to staff. Additionally, the administrartor will submit and a copy of the updated LIC 622 for all five residents to CCL to indicate the training was completed.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

LIC809 (FAS) - (06/04)

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