195850350-5-21-2024-29-AS-EPEI-D5GSW2-20240521141338

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850350
Report Date: 05/21/2024
Date Signed: 05/21/2024 02:14:35 PM

Document Has Been Signed on 05/21/2024 02:14 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:	LA SENIOR HOME		FACILITY NUMBER:	195850350
ADMINISTRATOR/ DIRECTOR:	SPRY, NAIRA		FACILITY TYPE:	740
ADDRESS:	7825 SIMPSON AVENUE		TELEPHONE:	(818) 299-7501
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY: 5		CENSUS: 4	DATE:	05/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:35 AM
MET WITH:	Tigran Gevorgyan and Alisa Manukyan		TIME VISIT/ INSPECTION COMPLETED:	02:25 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) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 10:35 a.m., the LPA met with staff and explained the reason for it visit. At 11:06 a.m., the Administrator Tigran Gevorgyan and staff, Alisa Manukyan arrived at the facility. RECORD REVIEWS: Between 11:15 a.m. and 12:10 p.m., the LPA conducted a file review for all four (4) residents. Resident records were reviewed for, but not limited to care plans, medical assessments, admissions agreement, consent forms. The following was noted: Two (2) out of four (4) residents did not have a signed physician’s report/ medical assessments. The LPA had a discussion with the Administrator regarding the physician report/ medical assessments for Resident #1 and Resident #2. At 12:24 p.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. During the time of the visit, the LPA conducted interviews with two (2) out of four (4) residents. BEDROOMS: The facility is a single-story residential home with three (3) bedrooms for resident 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 two (2) bathrooms for resident's use. Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats/ materials. At 12:26 p.m., hot water measured between 109.1 and 112.2-degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels. Signs are posted throughout the facility restrooms to promote handwashing. Continued on LIC-809-C.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

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 05/21/2024 02:14 PM - It Cannot Be Edited

Created By: Emily Peraldi On 05/21/2024 at 01:35 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: LA SENIOR HOME	FACILITY NUMBER: 195850350
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. 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 (2) out of four (4) residents did not have a signed physician’s report/ medical assessments which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/31/2024
	Plan of Correction
1 2 3 4	The Administrator agreed to obtain signed physician’s report/ medical assessments for R1 and R2 by due date.

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

LICENSING EVALUATOR NAME:

Emily Peraldi

LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

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: LA SENIOR HOME	FACILITY NUMBER: 195850350
	VISIT DATE: 05/21/2024

NARRATIVE

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KITCHEN: The LPA observed the kitchen and dining area. Knives are stored in a locked drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 12:35 p.m., hot water measured at 106.0-degree Fahrenheit. Cleaning solutions are locked underneath the kitchen sink. Medications are stored in a locked kitchen cabinet. First aid kit is located inside the kitchen area.

OUTDOOR SPACE: At 12:30 p.m., the LPA observed the back patio which has a covered outdoor area for resident use. The property is gated. Passageways were free and clear from obstruction. There are no bodies of water on the premises. A laundry area is attached to the dwelling and is equipped with a washer and dryer. Detergents and cleaning supplies are stored inside the locked laundry storage area. On the property there is one (1) detached storage unit, one (1) locked storage shed and a detached second dwelling in the back, which is not licensed. The LPA had several conversations with the Administrator regarding the second dwelling and reminded the Administrator not to accept anyone who requires care and supervision.

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 05/21/2024. At 12:36 p.m., fire alarms/carbon monoxide detectors were tested and functioned properly. The LPA observed cameras in the common areas. There is an office area that is divided by sliding doors and it’s marked for employees only.

Administrator certificate is current and valid until 07/16/2025.

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 deficiency was cited (refer to LIC 809-D).

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC809 (FAS) - (06/04)

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