195850306-12-28-2023-29-AS-SURA-CYY8B4-20231228212142

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850306
Report Date: 12/28/2023
Date Signed: 12/28/2023 09:24:11 PM

Document Has Been Signed on 12/28/2023 09:24 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:	AAA JERUSALEM STARS		FACILITY NUMBER:	195850306
ADMINISTRATOR:	SOHEILA NOROOZI		FACILITY TYPE:	740
ADDRESS:	5945 CAPISTRANO AVE		TELEPHONE:	(818) 888-1706
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 6	DATE:	12/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:05 PM
MET WITH:	Kristina Adamyan		TIME COMPLETED:	06:45 PM

NARRATIVE

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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual inspection. The LPA was greeted by staff and informed them of the reason for the visit. Licensee Kristina Adamyan arrived shortly thereafter.

The LPA and the licensee 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.

Kitchen: Knives are stored in a locked drawer in the kitchen. The facility has a sufficient supply of perishable and nonperishable food. Additional food is located in the garage. There is an adequate supply of emergency food and water. Appliances were clean and all appeared functional. Kitchen, laundry and house cleaning supplies are stored in a locked cabinet in the kitchen and in the garage. At 1:27 p.m. the LPA and the licensee observed five cockroaches in a cupboard under the oven.

Bedrooms: The facility has six bedrooms. Five rooms are designated for resident use. There are four private resident bedrooms (Rooms #1, 2, 4, 5) and one shared room (Room #3). Room #3, Room #4, and Room #5 have direct exits to the outside. Rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. Lighting in the rooms appeared adequate. Room #6 is a designated staff room. At 12:30 p.m. the LPA and the licensee observed the staff's bedroom to be unlocked. Over the counter medication (Nexium) with one pill on top of the lid, was observed within reach of the residents. The Licensee promptly removed the medication and locked the room.
Bathrooms: There are four bathrooms, and out of the four bathrooms, one is designated as a staff bathroom. Restrooms are clean and sanitary with grab bars and non-skid surfaces. Rooms #3 and #5 have an attached bathroom. Restrooms were fully stocked. Hand-washing signs were observed in all restrooms. At 12:40 p.m. the LPA and the licensee observed shaving razors on top of the sink and under the sink, to be within reach of residents. The non-skid mat in the bathroom #1 was found to have mold.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

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 12/28/2023 09:24 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: AAA JERUSALEM STARS	FACILITY NUMBER: 195850306
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 as chemicals and cleaning solutions were accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/28/2023
	Plan of Correction
1 2 3 4	Licensee promptly removed all items that posed a danger to residents in care.

Type A

Section Cited

CCR

87555(b)(27)

General Food Service Requirements

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. 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 in five dead cockroaches were observed in kitchen cupboard below the oven, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/31/2024
	Plan of Correction
1 2 3 4	Licensee agreed to hired new pesticide compnay to fumigate affected areas in the kitchen, and will email invoice for the fumigation service to LPA via email.

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	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/28/2023 09:24 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: AAA JERUSALEM STARS	FACILITY NUMBER: 195850306
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(6)

Incidental Medical and Dental Care Services

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in three out of three medications were not listed in the centrally stored and distruction record, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/08/2024
	Plan of Correction
1 2 3 4	Livensee agreed to have medication training for all staff who assist with medication. Training shall be conducted a medical professional and the licensee will email the LPA the training agenda, hours of training, certification of professional providing the training, and sign in sheet of all staff attending the training.

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). 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 in seven shaving razors were observed on the bathroom sink top, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/28/2023
	Plan of Correction
1 2 3 4	Licensee quickly removed all the razors fro the bathroom.

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	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/28/2023 09:24 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: AAA JERUSALEM STARS	FACILITY NUMBER: 195850306
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. 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 in two out of two staff didnot have the required training, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/19/2024
	Plan of Correction
1 2 3 4	Licensee agreed to provide to direct services staff/caregivers training in the required topics for the 20 hour annual training.

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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

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: AAA JERUSALEM STARS	FACILITY NUMBER: 195850306
	VISIT DATE: 12/28/2023

NARRATIVE

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Common Areas: The common areas are appropriately furnished, and the lighting is adequate. Resident and staff records are stored in the garage. There is not a fireplace in the living room. Medications are stored in a locked closet near the entrance. Fire extinguishers were purchased on 11/26/2023. Smoke detectors and common monoxide detectors were tested and were operational at the time of the visit. There is a functioning telephone on the premises. Emergency exit plans are posted throughout the facility. Other required postings are near the front entrance.

Outdoor Area: The exterior passageways were clean and clear of any obstructions. There is a covered patio area at the back of the house with tables and chairs where residents can sit. There is a door w/gate with a self-latching mechanism for persons to enter the front yard. There is a locked storage shed in the back yard. There are no bodies of water on the premises at the present time. The garage is accessible from the house; the door was unlocked at the time of the visit at approximately 1:15p.m. The washer and dryer are in the garage, along with the cleaning supplies.

RECORDS: Records review began at 2:30 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Staff files were missing the annual required hours of training for staff.

MEDICATIONS: Medications review began at 4:23 p.m.; medications are centrally stored and locked in a cabinet in a closet; medications are labeled and checked for expiration dates. Medications were not properly documented on the centrally stored medications and destruction record. The following errors were observed during the medication review. Medication for one resident was discontinued by physician, but no note was found in the resident’s record. Additionally, three new medications were prescribed, and doctor’s new order was missing from resident’s record as well the new medications were not listed in the Centrally Stored and Destruction Record.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

LIC809 (FAS) - (06/04)

Page: 5 of 6

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: AAA JERUSALEM STARS	FACILITY NUMBER: 195850306
	VISIT DATE: 12/28/2023

NARRATIVE

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INFECTION CONTROL: 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 if the facility has a confirmed case of COVID-19.

Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies are cited (refer to LICs 9099-D).

The LPA reviewed the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster

Deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

LIC809 (FAS) - (06/04)

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