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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850293
Report Date: 04/17/2024
Date Signed: 04/17/2024 03:52:23 PM

Document Has Been Signed on 04/17/2024 03:52 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:NORTH RESIDENTIAL CARE INCFACILITY NUMBER:
195850293
ADMINISTRATOR/
DIRECTOR:		DURGARYAN, REBEKAFACILITY TYPE:
740
ADDRESS:7846 AGNES AVETELEPHONE:
(818) 404-0290
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 6DATE:
04/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Rebeka Durgaryan, Administrator Svetlana Petrosian, staffTIME VISIT/
INSPECTION COMPLETED:
04:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 9:50 a.m., the LPA met with staff and explained the reason for it visit. At 10:16 a.m., the Administrator arrived at the facility.

At 10:21 a.m., the LPA, along with Administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. At 10:10 a.m., the LPA conducted an interview with one (1) out of six (6) residents.

KITCHEN: The LPA observed the kitchen/dining area. Knives are stored in a locked safety box found on top of the kitchen counter. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 10:39 a.m., hot water measured at 110.0-degree Fahrenheit.

BEDROOMS: The facility is a single-story residential home with five (5) bedrooms, four (4) for resident use and one (1) for staff use. The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. RESTROOMS: The facility has three (3) bathrooms for resident's use. Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. At 10:30 a.m., hot water measured between 106.3 and 112.6-degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels. Signs are posted throughout the facility restrooms to promote handwashing.

OUTDOOR SPACE: At 10:33 a.m., the LPA observed the back and side patio which has a covered outdoor area for resident use. There is a gate on the side of the house designated for an emergency exit. The garage is attached and remains inaccessible to residents. Passageways were free and clear from obstruction. There are no bodies of water on the premises. Continued on LIC-809-C.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2024
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 04/17/2024 03:52 PM - It Cannot Be Edited


Created By: Emily Peraldi On 04/17/2024 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: NORTH RESIDENTIAL CARE INC
FACILITY NUMBER: 195850293

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87615(a)(5)
Prohibited Health Conditions
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (5) Residents who depend on others to perform all activities of daily living for them as set forth in Section 87459, Functional Capabilities.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as three (3) out of six (6) residents have no capacitiy/ depend on others for self-care and is neither on hospice nor did the facility submit an exception waiver request to admit or retain residents at the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2024
Plan of Correction
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The Administrator stated that she will Regulation 87615 and submit an exceptions for R1, R2, and R3 to CCL no later than 05/03/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kristin Heffernan
LICENSING EVALUATOR NAME:Emily Peraldi
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/17/2024 03:52 PM - It Cannot Be Edited


Created By: Emily Peraldi On 04/17/2024 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: NORTH RESIDENTIAL CARE INC
FACILITY NUMBER: 195850293

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87467(a)(3)
Resident Participation in Decisionmaking
(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in three (3) out of six (6) residents require updated appraisals/needs and service plan which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2024
Plan of Correction
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The Administrator stated that she will complete residents appraisals/ needs and service plan by due date.

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
LICENSING EVALUATOR NAME:Emily Peraldi
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024


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: NORTH RESIDENTIAL CARE INC
FACILITY NUMBER: 195850293
VISIT DATE: 04/17/2024
NARRATIVE
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COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished. The LPA observed the fire extinguishers to be fully charged and last purchased on 10/15/2023. At 2:06 p.m., fire alarms/carbon monoxide detectors were tested and functioned properly. Night lights were present in the hallways and passages. All exits have functioning auditory devices and were operational at the time of the visit. First aid kit is located near the front entrance. Medications are stored in locked cabinet located between the kitchen and common areas. The LPA observed cameras in the common areas.

RECORD REVIEWS: Between 10:47 a.m. and 12:30 p.m., the LPA conducted a file review for all residents and staff regularly scheduled. Staff records were reviewed for documents including, but not limited to health screening, TB test, staff training records, and fingerprint clearance. Staff have current first aid and training appeared to be completed. Resident records were reviewed for, but not limited to care plans, medical assessments, admissions agreement, consent forms. The following was noted: One (1) out of two (2) residents with dementia diagnosis did not have updated physician’s report/ medical assessments. Technical violation issued and discussed with Administrator. Three (3) out of six (6) residents require updated appraisals/needs and service plan. Three (3) out of six (6) residents need assistance/ depend on others to perform all activities of daily living (ADLs). The LPA had a discussion with the Administrator regarding Prohibited Health Conditions. Facility fire drill was last conducted on 01/08/2024 and disaster drill was last conducted on 01/10/2024. Administrator certificate is current and valid until 02/03/2026.

Due to time constraints the LPA will return to complete the annual at a later date.

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8 and California Health and Safety Code the following deficiencies were cited (refer to LIC 809-D).

Exit interview conducted. The Administrator authorized staff, Svetlana Petrosian to sign the report. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024
LIC809 (FAS) - (06/04)
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