195850280-10-25-2023-29-AS-CYEE-CWY2SW-20231025173950

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850280
Report Date: 10/25/2023
Date Signed: 10/25/2023 05:40:17 PM

Document Has Been Signed on 10/25/2023 05:40 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:	FRIENDSHIP VILLAGE RCF		FACILITY NUMBER:	195850280
ADMINISTRATOR:	MKRTCHIAN, VAHE		FACILITY TYPE:	740
ADDRESS:	12950 HAYNES ST		TELEPHONE:	(818) 414-0005
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY:	6	CENSUS: 6	DATE:	10/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Vahe Mkrtchian, Administrator		TIME COMPLETED:	05:45 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 Analyst(LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool and met with Vahe Mkrtchian, Administrator. The reason for today's visit was explained. The facility is a single storey family home consisting of a living room, dining room, kitchen, 5 bedrooms of which one is used for live-in staff, 2 common bathrooms and a attached garage. The facility is fire cleared for 5 NON-AMBULATORY and 1 BEDRIDDEN resident. Bedrooms #1-Bedroom #4 may be used for the one bedridden resident The following was observed on today's visit: the living room, dining room and kitchen have the appropriate furnishings and equipment all 4 of the resident rooms have the required furniture and most of the bed linens. No blankets or flat sheets were observed on any of the beds or extra linens in the linen closet. All the exit doors are equipped with auditory devices. The auditory devices in Bedroom #1 and Bedroom #2 were not operational. Batteries were replaced during the visit. Sufficient perishable foods for 2 days and non-perishable foods for 7 days were observed. Medications and hygiene products were observed stored in 1 locked hallway closet and the toxins in another closet. Additional cleaning supplies are stored in a locked cabinet under the kitchen sink. the 2 common bathrooms are equipped with a shower, a toilet and a sink. Grab bars and non-skid mats were observed. The water tested in the front bathroom read 119.3 degrees Fahrenheit and the water temperature in back bathroom read 120 degrees Fahrenheit. the only fire extinguisher located in the kitchen was purchased on 10/30/22 and a new will be purchased prior to expiration date.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

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 10/25/2023 05:40 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: FRIENDSHIP VILLAGE RCF	FACILITY NUMBER: 195850280
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(h)

Care of Persons with Dementia

(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above per tour of the facility, the home is completely enclosed with a wall and sliding driveway gates but the driveway gates do not have self closing latches or security features that would allow the gate to close or be secured to protect the safety of the residents. The gates are left open to allow for entry and exit, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/02/2023
	Plan of Correction
1 2 3 4	Licensee will determine how the drive way gate will be secured to protect the safety of prospective dementia residents in care and allow the other residents to exit and enter freely by 11/1/23

Type B

Section Cited

CCR

87705(j)

Care of Persons with Dementia: j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above per tour of the facility, the auditory devices located in Bedroom #1 and Bedroom #2 were not operational which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/01/2023
	Plan of Correction
1 2 3 4	Licensee will ensure that the auditory devices are tested monthly to ensure that they are operational. Licensee will replace the batteries and self certify that the batteries in Bedroom #1 and #2 have been replace and are operational. by 11/1/23 *****CORRECTED AT TIME OF THIS VISIT******

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/25/2023 05:40 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: FRIENDSHIP VILLAGE RCF	FACILITY NUMBER: 195850280
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(a)(3)(C)

Personal Accommodations and Services: Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide.... (C)Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above per tour of the resident rooms, the residents beds were observed without blankets and flat sheets and there were no extra linens observed in the linen closet which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/01/2023
	Plan of Correction
1 2 3 4	Licensee will purchase extra sets of bed linens consisting of fitted sheets, flat sheets, pillow cases and blankets in quantities that will allow for weekly changing or as as frequently as needed by 11/01/23

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/25/2023 05:40 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: FRIENDSHIP VILLAGE RCF	FACILITY NUMBER: 195850280
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(a)(8)(A)

Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: 8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above per review of the first aid kit, that the facility does no have a first aid manual which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/01/2023
	Plan of Correction
1 2 3 4	Licensee will purchase a current first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency by 11/1/23

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FRIENDSHIP VILLAGE RCF	FACILITY NUMBER: 195850280
	VISIT DATE: 10/25/2023

NARRATIVE

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the facility has a first aid kit with the required tweezer and scissors and a common thermometer. No first aid manual was observed.
the facility has a land line with a telephone # (818)358-3286
the facility has current liability insurance that meets the required $1 million per incident for a total annual aggregate of $3 million.
the smoke/carbon monoxide combination detectors located in the resident bedrooms and in the hallway are hardwired and were tested and were operational.
Per tour of the outside, both the front and back of the facility has a covered patio with seating for residents and were observed to be clean and well maintained. Located in front of the home, along the left side of the facility and the back are ramps that allow residents direct access to the outside
trash cans located in the front were observed tightly sealed.
all staff and resident records were reviewed during today's visit

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

Exit interview was conducted, APPEALS RIGHTS were discussed and a copy was given

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC809 (FAS) - (06/04)

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