195850296-10-6-2023-29-AS-BBAI-CWCSYV-20231006141810

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850296
Report Date: 10/06/2023
Date Signed: 10/06/2023 02:18:38 PM

Document Has Been Signed on 10/06/2023 02:18 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:	COMPLETE HARMONY BOARD AND CARE INC		FACILITY NUMBER:	195850296
ADMINISTRATOR:	YEGISHYAN, VREJ		FACILITY TYPE:	740
ADDRESS:	14912 GILMORE ST		TELEPHONE:	(818) 239-6550
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91411
CAPACITY:	6	CENSUS: 3	DATE:	10/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Nuritsa Martinyan - Assistant Administrator		TIME COMPLETED:	02:30 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 8:30am. LPA met with Staff and explained the reason for the visit. Assistant Administrator Nuritsa Martinyan arrived shortly after. At approx. 9:00am, 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 (5) non-ambulatory residents and (1) bed ridden resident, with bed ridden resident will be residing in room #2; The facility has (2) private resident bedrooms, Rooms #3 and #4 and (2) shared room(s), Room #1 and #2. Resident rooms # 2 and #3 have direct exits to the outside. During physical plant tour LPAs observed the required postings throughout the facility. At approx. 8:40am, LPA observed staff servicing resident. 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 locked box located in a cabinet to the left of the sink. No cleaning supplies or toxins are stored under the sink. Personal hygiene items (shampoos, soaps) were adequate and are stored in the hallway closet Extra incontinence supplies are stored in hallway closet as well. 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. LPA observed bathrooms to be clean, properly supplied and had functional fixtures. LPA observed bathroom 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: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

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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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: COMPLETE HARMONY BOARD AND CARE INC	FACILITY NUMBER: 195850296
	VISIT DATE: 10/06/2023

NARRATIVE

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Continued from 809
LPA observed the common areas. These included the living room, office area and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. . Medications are stored in a locked cabinet next to the dining table. LPA observed it to be inaccessible to residents in care. There is a dedicated area for the posting of required documents directly by the entry way. There is a fireplace in the living room that is non-operable at this time. It is screened and there are no tools. 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 in October 2023. All exits in the facility have functioning auditory devices and were operational at the time of the visit.

The exterior passageways were clean and clear of any obstructions. The entire property is 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 front courtyard has a gate with a self-latching mechanism for persons to enter the front courtyard. LPA observed appropriate furniture for outdoor use. There is an attached garage, but is inaccessible from the home. The garage is currently used for storage for old furniture and medical equipment for the property owner. There are two (2) storage sheds located in the rear of the facility. LPA observed both to store extra medical supplies, old furniture, tools and extra medical equipment. LPA observed gardening tools in the storage shed at this time. There are no bodies of water on the premises at the present time. There is an attached Adult Dwelling Unit (ADU) connected to the facility, it was observed to be inaccessible to residents in care at this time. There is a separate entrance and a separate address. LPA observed it to be empty at this time.

Records review began at 10:00 am, three (3) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. All files were observed to be in order at this time. At approx. 11:30am, four (4) 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. 11:55am, LPA observed Staff #1 (S1) has criminal record clearance, but they 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: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

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: COMPLETE HARMONY BOARD AND CARE INC	FACILITY NUMBER: 195850296
	VISIT DATE: 10/06/2023

NARRATIVE

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Continued from 809-C

Medications: Medications review began at approximately 10:30am. The medications are centrally stored in a locked storage cabinet near the office area. Medications were observed to be properly documented on the centrally stored medications and destruction record.

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 residents 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 11am - 12pm the LPA interviewed two (2) staff members and interviewed two (2) residents.

LPAs obtained the following documents - Census, Staff schedule, Back up Administrator Documents 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 $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: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/06/2023 02:18 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: COMPLETE HARMONY BOARD AND CARE INC	FACILITY NUMBER: 195850296
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 S1, which poses an immediate health, safety and personal rights risk to persons in care.
	POC Due Date: 10/09/2023
	Plan of Correction
1 2 3 4	Licensee agreed to submit a transfer of a criminal record clearance for S1 not associated to the facility by 10/09/2023. Licensee will submit proof of clearance to LPA via email by eod 10/09/2023.

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

LIC809 (FAS) - (06/04)

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