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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850349
Report Date: 08/17/2023
Date Signed: 08/17/2023 05:35:42 PM


Document Has Been Signed on 08/17/2023 05:35 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:LOVING CARE FACILITY INC.FACILITY NUMBER:
195850349
ADMINISTRATOR:NSHANYAN, HASMIKFACILITY TYPE:
740
ADDRESS:15107 BURTON STTELEPHONE:
(310) 993-2441
CITY:PANORAMASTATE: CAZIP CODE:
91402
CAPACITY:4CENSUS: 2DATE:
08/17/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Hasmik Nshanyan AdministratorTIME COMPLETED:
05:40 PM
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Licensing Program Analysts (LPAs) Emily Peraldi and Martha Arroyo conducted a Case Management – Deficiencies to issue citations for deficiencies observed during an unrelated complaint investigation. Entrance interview conducted.

Prior to visit, LPA Peraldi printed out the facility personnel report summary from the Licensing Information System (LIS). Upon arrival, it was revealed Staff #1 (S1) is the main caregiver during the week. Per record review, conducted by LPAs on the Guardian website, S1 does not have fingerprint clearance. Interviews with the Administrator revealed that S1 started working at this facility on July 27, 2023. The Administrator explained that S1 will obtain their fingerprint clearance. The LPAs reminded the Administrator that staff that are not fingerprinted or are not associated to the facility cannot be working at the facility. The Administrator stated that the facility will ensure that all staff will have a criminal record clearance and are associated to the facility prior to working at the facility.

Additionally, the LPAs had a conversation with the Administrator regarding the Unlicensed complaint that the Department received on 08/14/2023 located at the accessory dwelling unit (ADU) at the back of the facility. The Administrator stated that the ADU is not licensed and is an independent living facility and that she is not part of the operation. The Administrator explained that the Operator of the independent living facility has their own lease agreement and only accepts tenants who do not require aspects of care and supervision. Information obtained and reviewed from investigation conducted on 08/17/2023, revealed that one (1) out of three (3) tenants (Tenant #1) were found to require assistance with activities of daily living such as but not limited to medication management, bathing, and dressing. Furthermore, record review and interviews conducted revealed the Administrator misrepresented the facility by accepting a resident who required care and supervision and was placed in the independent living facility located in facility’s ADU.
Continued on LIC 809-C.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023
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: LOVING CARE FACILITY INC.
FACILITY NUMBER: 195850349
VISIT DATE: 08/17/2023
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During the interview with the Administrator, it was revealed that one of the residents was hospitalized on July 23, 2023 and the Administrator did not send an incident report regarding the hospitalization to the Department. The LPAs reminded the Administrator that a written report shall be submitted to the licensing agency within seven days of the occurrence of any of the events such as a hospitalization.

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

Exit interview conducted, today's reports and appeal rights were provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/17/2023 05:35 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: LOVING CARE FACILITY INC.
FACILITY NUMBER: 195850349

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/18/2023
Section Cited
CCR
87355(e)(1)

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 87355(e)(1) Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Healthh...all prior to working...(1) Obtain a California clearance... as required by the Department… This requirement is not met as evidenced by:
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Licensee agreed to get S1 a criminal record clearance and ensure all staff are associated to the facility by 08/17/2023.
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Based on record review and interviews conducted, the licensee did not comply with the section cited above as S1 does not have a criminal record clearance which poses an immediate health, safety and personal rights risk to persons in care.
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Type A
08/18/2023
Section Cited
HSC1569.58(2)

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HSC-1569.58(2) Engaged in conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility… This requirement is not met as evidenced by:
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The Administrator will review H&S Code 1569.58 and submit a statement of understanding to CCL by poc due date.
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Based on interviews conducted, the licensee did not comply with the section cited above as the Administrator misrepresented the facility by taking a resident needing assistance with ADLs and placing them in the independent living facility, which poses an immediate safety risk to persons in care.
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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 HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 08/17/2023 05:35 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: LOVING CARE FACILITY INC.
FACILITY NUMBER: 195850349

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/21/2023
Section Cited
CCR
87211(a)(1)

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87211(a)(1)Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency...This requirement is not met as evidenced by:
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The Administrator agreed to submit the incident report to the Department by 08/21/2023.
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Based on interview and record review, the licensee did not comply with the section cited above, as an incident report was not submitted for a resident’s hospitalization which poses a potential health and safety risk to residents in care.
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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 HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4