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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604809
Report Date: 04/20/2022
Date Signed: 04/20/2022 04:03:02 PM

Document Has Been Signed on 04/20/2022 04:03 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
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: 5DATE:
04/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:23 PM
MET WITH:Karine Filikyan - Administrator TIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced annual visit at the facility with focus on infection control, food and medication review. LPA Flores met with Susanna Babayan Caregiver and explained the reason for the visit. Administrator arrived 10 minutes after.

Facility is licensed for six (6) non-ambulatory clients age 60 and above, of which six (6) may be bedridden in rooms #1, #2, and #3. Facility is approved for one (1) hospice waiver. Facility is a single home located in a residential area, has a kitchen, dining room, living room, 5 resident bedrooms, 2 bathrooms, a front and back yard, and a detached garage. No large bodies of water were observed.

LPA Flores conducted a tour of the facility with Karine Filikyan administrator and observed the following:
Kitchen area - facility has sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables. Medication was observed in drawer across from the stove, cleaning supplies under sink, and cooking knives in drawers to the left of the sink unlocked at the time of the visit. Fire extinguisher was observed on the wall in the kitchen doorway. Living room was observed to have a cover fireplace. All bedrooms have sufficient lighting, all bedding and furniture required. Bathroom #1(B1) and #2(B2) was observed with grab bars and skid mats, water was tested in B1 at 124.9 degrees F., and B2 at 124.4 degrees F., which is not within the required 105-120 degrees F. LPA reviewed medication and files for 5 residents and flies for staff #1,#2,#3. Exit door to street, exit doors in living room and residents room with access to backyard were observed and no auditory device was heard or observed. Administrator certificate was observed for Karine Filikyan #6024067740 expiration date 1/21/21, per administrator renewal documents have been submitted and is waiting for certificate.
LPA has noted technical assistance regarding infection control recommendations. Deficiencies have been noted on LIC 809D under Title 22 Regulations.
Exit interview was conducted with Karine Filikyan administrator and a copy of this report, LIC 809D and appeal rights were provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 8
Document Has Been Signed on 04/20/2022 04:03 PM - It Cannot Be Edited


Created By: Mary G Flores On 04/20/2022 at 03:20 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CHATEAU MAGNOLIA
FACILITY NUMBER: 197604809

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in B1 water temperature was tested at 124.9 degrees F. and B2 water temperature was tested at 124.4 degrees F. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2022
Plan of Correction
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Licensee will ensure water temperature is kept within the required 105 - 120 degrees F. at all times and will certify in LIC 9098 by 4/21/22. Licensee will maintain a water temperature log for the next 7 days and submit to the department by 4/27/22.
Type A
Section Cited
CCR
87309(a)(1)
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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in cleaning supplies under the sink, medication on drawer across the stove, and cooking knives on drawers to the left of the sink were not lock which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2022
Plan of Correction
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Licensee will ensure all cleaning solutions, chemicals, medication, and sharps at lock at all times by certifying in LIC 9098 and submit to the department by 4/21/22.
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:Stefanie Coronel
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2022


LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 04/20/2022 04:03 PM - It Cannot Be Edited


Created By: Mary G Flores On 04/20/2022 at 03:20 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CHATEAU MAGNOLIA
FACILITY NUMBER: 197604809

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in main entrance, exit door to the backyard, and exit door on bedroom #5 did not have an auditory device which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2022
Plan of Correction
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Licensee is to install auditory devices chime in all exit doors to ensure the safety of dementia residents in care and submit a picture to the department by 4/21/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Stefanie Coronel
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2022


LIC809 (FAS) - (06/04)
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