195850263-9-21-2023-29-AS-BBAI-CVVVLA-20230921163137

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850263
Report Date: 09/21/2023
Date Signed: 09/21/2023 04:34:03 PM

Document Has Been Signed on 09/21/2023 04:34 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:	PRIME SENIOR LIVING, INC		FACILITY NUMBER:	195850263
ADMINISTRATOR:	NSHANIAN, HERMINE		FACILITY TYPE:	740
ADDRESS:	8123 PASO ROBLES AVE		TELEPHONE:	(818) 913-3309
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91406
CAPACITY:	6	CENSUS: 6	DATE:	09/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:09 PM
MET WITH:	Elena Kordonskiy- Asst Administrator		TIME COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit at 1pm. Upon arrival LPA met with Administrative Assistant Elena Kordonskiy and explained the reason for the visit. 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. The facility is one story. An approved fire clearance was received, clearing them for 6 ambulatory residents; The facility has (3) resident bedrooms and (1) staff room. Staff room as observed to be empty during the visit. During physical plant tour LPAs observed the required postings throughout the facility. Kitchen: The kitchen appeared to be clean and the appliances and fixtures functional during the time of visit. LPAs observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects are stored in a cabinet in the kitchen to the right of the oven. Cleaning supplies are stored under the sink locked and inaccessible to residents in care. Medications were observed stored in a locked file cabinet in the kitchen inaccessible to residents in care. Bedrooms: The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Bathrooms: LPAs observed all bathrooms were clean, properly supplied and had functional fixtures. LPA observed all bathrooms to have grab bars and non-skid mats. The hot water was measured in each bathroom between 110 - 113 degrees Fahrenheit.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

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 09/21/2023 04:34 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PRIME SENIOR LIVING, INC	FACILITY NUMBER: 195850263
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87204(b)

Limitations -Capacity and Ambulatory Status

(b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nonambulatory shall not remain in rooms restricted to ambulatory residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review the licensee did not comply with the section cited above as R1 is listed as non-ambulatory and is currently residing in a room that is cleared for Ambulatory only, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 09/22/2023
	Plan of Correction
1 2 3 4	Within 24 hours, the Licensee agreed to relocate R1 to a facility 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

Type A

Section Cited

CCR

87355(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above by not transferring the criminial record clearance for the Assistant Administrator and S1, which poses an immediate health, safety and personal rights risk to persons in care.
	POC Due Date: 09/22/2023
	Plan of Correction
1 2 3 4	Licensee agreed to submit a transfer of a criminal record clearance for all staff not associated to the facility by 11/04/2022. Licensee will submit proof of clearance to LPA via email by eod 09/22/2023.

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	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/21/2023 04:34 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PRIME SENIOR LIVING, INC	FACILITY NUMBER: 195850263
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as (2) out of (5) staff files reviewed did not have a valid first aid / CPR certification on file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/29/2023
	Plan of Correction
1 2 3 4	LIcensee scheduled first aid and CPR renewel for 09/22/2023 and agreed to have all staff files to be complaint with first aid and CPR notification. Licensee also willl submit proof of certification via email to CCL by COB 09/29/2023.

Type B

Section Cited

CCR

87463(a)

Reappraisals

(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review , the licensee did not comply with the section cited above as Four (4) out of the six (6) resident records reviewed were missing LIC 625 appraisal/needs and services plan, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/29/2023
	Plan of Correction
1 2 3 4	Licensee agreed to maintain full resident files in the facility. Licensee also agreed to submit proof of understanding of regulation cited and submit to LPA via email by EOD 09/29/2023.

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	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PRIME SENIOR LIVING, INC	FACILITY NUMBER: 195850263
	VISIT DATE: 09/21/2023

NARRATIVE

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Continued from 809

Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a dedicated area for the posting of required documents directly by the entry way into the kitchen. The common areas were observed to be properly furnished and relatively clean at the of the visit. LPA observed appropriate signage regarding infection control posted throughout the facility. LPA observed sanitizer readily available in areas with high touch surfaces. Common room furniture was observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detectors were operational at the time of the visit. Fire extinguishers were observed fully charged and purchased------.

Outdoor Area: There is a covered patio area at the back of the house with tables and chairs where residents can sit. The entire property is not fenced. The back and sides of the house are separated from the front yard by gates at the north and south side passageways. The gate to the driveway is moved manually. There is a door w/gate with a self-latching mechanism for persons to enter the front yard. There is a detached Adult Dwelling Unit (ADU) located in the rear of the facility. LPA met with facility staff who currently resides in the ADU. No health and safety hazards were observed in the ADU at this time. There are no bodies of water on the premises at the present time.

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

RECORDS: Records review began at 01:45 pm, six (6) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. At 2pm, LPA observed Four (4) out of the (6) resident records reviewed were missing LIC 625 appraisal/needs and services plan.

Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. At approx. 02:20pm, LPA observed, (2) out of (5) staff files reviewed do not have a valid first aid / CPR certification on file. LPA observed Administrator schedule first aid / CPR to be completed for the (2) staff by 09/29/2023. At approx. 2:25pm, LPA observed Assistant Administrator and Staff #1 (S1) staff have criminal record clearance, but are not associated to this facility.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PRIME SENIOR LIVING, INC	FACILITY NUMBER: 195850263
	VISIT DATE: 09/21/2023

NARRATIVE

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Continued from 809-C
Medications: Medications review began at approximately 03:30pm . The medications are centrally stored in a med cart in the living room. Medications were observed to properly documented on the centrally stored medications and destruction record at this time.

Infection Control : Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of a communicable disease. 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 or relocate a resident if the facility has a confirmed case of a communicable disease. The facility’s policies and procedures as it pertains to infection control are adequate at this time.

Between 4:00pm - 4:30pm the LPAs interviewed three (3) staff members and three (3) residents.

LPAs obtained the following documents - Census, Staff schedule, Emergency Disaster plan and updated Limited Liability insurance.

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to Lice 809-D). Civil penalties assessed in the amount of $1,500. Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted, appeal rights provided and a copy of the report issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

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