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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604809
Report Date: 06/22/2023
Date Signed: 06/22/2023 11:27:35 AM

Document Has Been Signed on 06/22/2023 11:27 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME:CHATEAU MAGNOLIAFACILITY NUMBER:
197604809
ADMINISTRATOR:KARINE FILIKYANFACILITY TYPE:
740
ADDRESS:1061 EAST MAGNOLIA ST.TELEPHONE:
(818) 843-5873
CITY:BURBANKSTATE: CAZIP CODE:
91501
CAPACITY: 6CENSUS: 4DATE:
06/22/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Karine FilikyanTIME COMPLETED:
11:30 AM
NARRATIVE
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During the course of complaint investigation # 28-AS-20220607104211 issued on 06/07/2022 the following deficiency was observed:
87405(d)(5)- the administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
Good character and a continuing reputation of personal integrity.

87405 (d)(5) Administrator was not forthright with the Department by denying knowledge of the incident and saying client left because of constipation issues and did not disclose the incident.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2023
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 06/22/2023 11:27 AM - It Cannot Be Edited


Created By: Glenn Trueman On 06/14/2023 at 04:19 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
,
, CA

FACILITY NAME: CHATEAU MAGNOLIA
FACILITY NUMBER: 197604809

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/26/2023
Section Cited
CCR
87405(d)(5)

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Administrator - Qualifications and Duties
The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply Good character and a continuing reputation of personal integrity.
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Administrator to review Title 22 Regulations and submit self certification by POC due date that she will show good character and integrity at all times.
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This requirement is not met as evidenced by:
Administrator was not forthright with the Department by denying knowledge of the incident and saying client left because of constipation issues and did not disclose the incident 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:Wei Siew Ho
LICENSING EVALUATOR NAME:Glenn Trueman
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023


LIC809 (FAS) - (06/04)
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