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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850239
Report Date: 01/07/2025
Date Signed: 01/07/2025 04:49:33 PM

Document Has Been Signed on 01/07/2025 04:49 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:SILVER LIGHT CAREFACILITY NUMBER:
195850239
ADMINISTRATOR/
DIRECTOR:		KHACHATRYAN, ELBAFACILITY TYPE:
740
ADDRESS:8201 VANTAGE AVENUETELEPHONE:
(747) 228-4111
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 5DATE:
01/07/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:46 AM
MET WITH:Kina NkumbulaTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility to conduct an unannounced Case Management- Deficiencies inspection.

During record review LPA observed Resident #1’s (R1) file. R1’s file was observed to contain an incomplete hospice care plan. Resident #2’s (R2) file was observed to contain blank pre-placement appraisal information, appraisal needs and services plan, and client personal property and valuables sheets. Additionally, R2’s file was missing a physician’s report. Resident #3’s (R3) file was observed to have an admission date of 09/25/2024 and a physician’s report dated 01/12/2023 which is outside of the required 12-month timeframe required prior to admission. Interviews with the facility Administrator revealed that they charge resident’s additional fees for requested snacks that are not normally available on the facility’s menu. The facility’s admission agreement states, “If requested, special food products purchased for an individual resident will be itemized on a monthly statement and charged at facility’s cost.” The Administrator stated that they have not provided resident’s representatives with an itemized receipt for these purchases.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies was cited (refer to LIC 809-Ds): Exit interview conducted and copy of the report was issued and appeal rights provided.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 01/07/2025 04:49 PM - It Cannot Be Edited


Created By: Trevor Byrne On 01/07/2025 at 03:48 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: SILVER LIGHT CARE
FACILITY NUMBER: 195850239

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/21/2025
Section Cited
CCR
87457(c)

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87457 Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs...
This requirement is not met as evidenced by:
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Licensee will submit the completed pre-admission appraisal for Resident 2 to CCLD no later than POC due date.
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Based on interview and record review the licensee did not comply with the section cited above as R2's file did not contain a filled out pre-admission appraisal which poses a potential health, safety, and personal rights risk to clients in care.
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Type B
01/21/2025
Section Cited
CCR87218(a)(1)

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87218 Theft and Loss
(a) The licensee shall ensure an adequate theft and loss program...
(1) The initial personal property inventory shall be completed by the licensee, and the resident, or the resident’s representative.
This requirement is not met as evidenced by:
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Licensee will submit proof of a filled out property and valuables sheet for R2 to CCLD no later than POC due date.
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Based on interview and record review the licensee did not comply with the section cited above as R2's file did not contain a filled out resident personal property and valuables sheet which poses a potential personal rights risk to clients 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:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 01/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/07/2025


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/07/2025 04:49 PM - It Cannot Be Edited


Created By: Trevor Byrne On 01/07/2025 at 04:04 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: SILVER LIGHT CARE
FACILITY NUMBER: 195850239

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/21/2025
Section Cited
CCR
87458(a)

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87458 Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment...made within the last year, to be kept in the resident's record.
This requirement is not met as evidenced by:
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Licensee will submit updated medical assessments for R2 nd R3 to CCLD no later than POC due date.
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Based on record review the licensee did not comply with the section cited above as R2's file did not contain a medical assessment and R3's file contained an assessment dated 20 months prior to their admission which poses a potential health and safety risk to clients in care.
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Type B
01/21/2025
Section Cited
CCR87633(b)

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87633 Hospice Care of Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:
This requirement is not met as evidenced by:
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Licensee will submit completed hospice paperwork for R1 to CCLD no later than POC due date.
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Based on record review the licensee did not comply with the section cited above as R1's file contained incomplete hospice paperwork which poses a potential health, safety, and personal rights risk to clients 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:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 01/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/07/2025


LIC809 (FAS) - (06/04)
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