197607518-7-27-2023-29-AS-AASO-CU62JP-20230727172642

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607518
Report Date: 07/27/2023
Date Signed: 07/27/2023 05:30:25 PM

Document Has Been Signed on 07/27/2023 05:30 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:	VILLAGE CARE		FACILITY NUMBER:	197607518
ADMINISTRATOR:	GOHAR GIGI PAPAZIAN		FACILITY TYPE:	740
ADDRESS:	12245 CALIFA STREET		TELEPHONE:	(818) 516-1749
CITY:	VALLEY VILLAGE	STATE: CA	ZIP CODE:	91607
CAPACITY:	6	CENSUS: 4	DATE:	07/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Don Aquino		TIME COMPLETED:	05:40 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) Angel Ascencio conducted unannounced required annual inspection to the above facility. LPA Ascencio met with staff at 09:45 a.m. Entrance interview conducted. Administrator Gigi Papazian and Alin Papazian arrived shortly after. The LPA toured the physical plant areas inside and outside at approximately 10:00 a.m. to ensure that there are no health and safety hazards. KITCHEN: At 10:00 a.m., the LPA toured the Kitchen. The supply of dishes, utensils, pots, pans and drink ware is adequate. The freezer was maintained at zero degrees Fahrenheit (0F) and the refrigerator was maintained at 40F. The supply of perishable and nonperishable food is adequate. LAUNDRY: At 10:05 a.m., the LPA observed the laundry area which is located in next to the kitchen. Appliances were clean, sanitary and in operable condition. BEDROOMS: There are four (4) bedrooms designated for resident use. All rooms are approved as bedridden rooms. Bedroom #1 and #2 are single occupancy. Bedroom #3 and #4 are double occupancy with exits to the exterior. Bedroom #3 and #4 also have bathroom within the rooms. The facility has furnished each room with clean linens, appropriate furnishings, and sufficient lighting for resident use. Storage space cabinet in hallway was observed containing clean linens for resident use. BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. Continued on LIC 809-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

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: VILLAGE CARE	FACILITY NUMBER: 197607518
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/27/2023

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 Raid, Fabuloso, Gain Laundry Detergent (4 bottles), Clorox was observed unlocked at various parts of the house which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/28/2023
	Plan of Correction
1 2 3 4	Administrator will secure items and conduct staff training on 87309(a). Administrator will send materials to CCL.

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. 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 the medication cabinet was unlocked, Hydrogen Peroxide in unlocked restroom, Vaseline, A&D Ointment, Diclofenac Sodium %1 , Neosporin, Calmoseptine, Polysporin, Hydrophilic Wound Dressing, Anti-Fungal Powder in Resident Restroom, Sulful Zinc Oxide Salicylic Acids, diclofenac sodium 1% unlocked garage which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/28/2023
	Plan of Correction
1 2 3 4	Administrator will secure items and conduct staff training on 87465(h)(2). Administrator will send materials to CCL

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	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLAGE CARE	FACILITY NUMBER: 197607518
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 as Garage door was unlocked containing Tool box with hammer, screwdriver, and a Lighter was observed in an unlocked kitchen drawer which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/28/2023
	Plan of Correction
1 2 3 4	Administrator will secure items and conduct staff training on 87705(f)(1). Administrator will send materials to CCL.

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	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/27/2023 05:30 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: VILLAGE CARE	FACILITY NUMBER: 197607518
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(d)

Personnel Records

(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above as there is no active administrator present, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/18/2023
	Plan of Correction
1 2 3 4	Administrator will submit information for recertification or appoint a new Administrator. Send appropriate documents to CCL by 08/18/2023.

Section Cited

Resident Records


	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	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/27/2023 05:30 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: VILLAGE CARE	FACILITY NUMBER: 197607518
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(5)(A)

Postural Supports

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. 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 1 out of 4 residents did not have bed rail orders, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/18/2023
	Plan of Correction
1 2 3 4	Administrator will contact the residents doctor to obtain bed rail order if appropriate. Administrator will submit documentation to CCL by 08/18/2023.

Type B

Section Cited

CCR

87705(g)

Care of Persons with Dementia

(g) As required by Section 87468(a)(12), residents with dementia shall be allowed to keep personal grooming and hygiene items in their own possession, unless there is evidence to substantiate that the resident cannot safely manage the items. 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 mouthwash, shampoo, conditioner in shower not locked, Nail polish in Resident room, Vaseline in resident room, Body wash in restroom, Shaving gel, A&D Ointment in resident room, Box of shampoo in unlocked garage which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/18/2023
	Plan of Correction
1 2 3 4	Administrtor will secure items. Administrator will conduct staff training on 87468(a)(12) and submit copies of materials to CCL by 08/18/2023.

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	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/27/2023 05:30 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: VILLAGE CARE	FACILITY NUMBER: 197607518
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(a)

87307(a) Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. 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 during a physical plant, LPA observed RING cameras installed in all resident rooms which poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 08/18/2023
	Plan of Correction
1 2 3 4	Administrator will remove all cameras from resident rooms. In addition, cameras in common areas should only be used for video and no audio. Administrator will submit an updated plan of operation if facility were to keep common area cameras. Administrator agreed to review section cited and submit statement of understanding to CCL.

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	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLAGE CARE	FACILITY NUMBER: 197607518
	VISIT DATE: 07/27/2023

NARRATIVE

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COMMON SPACES: The common spaces included the living room and dining area. The LPA observed
cameras in the common areas. A TV for resident use including games in a storage cabinet. All common
areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common
seating area and dining room furniture was observed to be in good condition. Chairs were observed to be at
least 6 (six) feet apart for social distancing. The LPA observed the required postings in the common hallway.
Fire extinguishers were observed to be serviced within the last year. The facility smoke alarm system and carbon monoxide detector was tested and operated normally at the time of visit. Medications were observed to be locked in a cabinet next to the kitchen and contained at least 30 days of worth of medication.

INFECTION CONTROL: There is 1 entry into the facility. Upon entry, the facility has a central entry point for
symptom screening. The LPA noted that the facility is allowing visitors for both indoor and outdoor visitation.
The LPA observed an adequate supply of Personal Protective 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. The facility
does not have a confirmed case of COVID-19 at this time. The facility’s policies and procedures as it pertains
to infection control are adequate.

The following was observed during today's visit:

At 10:03 a.m., during kitchen tour, LPA observed an knife on top of the counter, an unlocked drawer full of knifes, and a pair of scissors in the sink.
At 10:09 a.m., during common restroom tour, LPA observed 3% hydrogen peroxide, lighter, mouthwash, shampoo, conditioner and body wash accessible to resident in care.
At 10:10 a.m., during resident room and private restroom tour, LPA observed case of nail polish, Vaseline, body wash, A&D Ointment, Skintimate shaving cream, neosporin, calmoseptine, Diclofenac Sodium %1 (Prescribed medication), Anti-Fungal Powder, Polysporin, and Triad Hydrophilic Wound Dressing.

Continued on LIC 809 - C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLAGE CARE	FACILITY NUMBER: 197607518
	VISIT DATE: 07/27/2023

NARRATIVE

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At 10:18 a.m., during garage tour, LPA observed an unlocked garage that contained, sulfur zinc oxide salicylic acid, Gain laundry detergent (x4), Box of Clorox, Box of Shampoo (18), Fabuloso, Diclofenac Sodium topical gel, a tool box with a hammer and screwdriver, and Raid Max Fogger.
At 11:10 a.m., LPA observed RING cameras in all resident rooms.
At 11:20 a.m., during staff file review, LPA did not observe active Administrator Certificate for Gohar Gigi Papazian. LPA checked the CCLD website in Active and Pending List. LPA did not observed a certificate active or pending.
At 12:00 p.m., during file review, 1 out of 4 residents did not have bed rail orders.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit interview conducted and a copy of the report and appeal rights were issued.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

LIC809 (FAS) - (06/04)

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