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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608325
Report Date: 07/22/2021
Date Signed: 07/22/2021 01:34:49 PM

Document Has Been Signed on 07/22/2021 01:34 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,
, CA
FACILITY NAME:ZANN DAILY CAREFACILITY NUMBER:
197608325
ADMINISTRATOR:ANN SOLAKYANFACILITY TYPE:
740
ADDRESS:11500 BAIRD AVENUETELEPHONE:
(818) 635-9471
CITY:NORTHRIDGESTATE: CAZIP CODE:
91326
CAPACITY: 6CENSUS: 5DATE:
07/22/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ana SolakyanTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Martha Guzman Chavez conducted an unannounced Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint control # 31-AS-20190723103029). Upon arrival, LPA was greeted at the door by Caregiver Zaruhi. LPA met with administrator Ana Solakyan at 11:25am. The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint.

On 07/24/2019, LPA Perera conducted an initial 10-day visit, at which time copies of pertinent documents from Resident #1 (R1) facility file was obtained and reviewed. On 07/24/2019 at 8:55am, LPA conducted a tour of the physical plant and interviews were conducted with administrator and staff at 9:10am. During the course of the investigation, it was revealed that the facility failed to assess Resident #1 (R1) prior to accepting R1 to the facility. Additionally, the facility failed to maintain any records for R1 including but not limited to a care plan, physicians report, needs and services plan and reappraisals.


Pursuant to Title 22, California Code of Regulations, the following deficiency will be cited (refer to LIC 9099-D

Exit interview conducted, appeal rights discussed, and a copy of this report has been issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2021
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 07/22/2021 01:34 PM - It Cannot Be Edited


Created By: Martha Guzman-Chavez On 07/22/2021 at 11:48 AM
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: ZANN DAILY CARE
FACILITY NUMBER: 197608325

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/26/2021
Section Cited
CCR
87457(c)

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87457(c) Pre-Admission Appraisal – General. (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs…

This requirement is not met as evidenced by:
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Administrator stated that she will review Section 87457 and provide CCL with a statement of understanding of the regulation on or before 07/26/2021.
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Based on interviews and record review, licensee did not comply with the above section by not completing a pre-admission appraisal for R1 prior to accepting and retaining R1 in the facility, which poses a potential health and safety risk to resident in care.
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Type B
07/26/2021
Section Cited
CCR87506(a)

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87506(a) Resident Records. The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
This requirement is not met as evidenced by:
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Administrator will provide written documentation of her plan for ensuring that residents' records are readily accessible to staff. Administrator will submit this documentation to CCL on or before 07-26-2021.
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Based on record review, observation and interviews, licensee did not comply with the above section by not maintain a complete file for 1 out of 1 residents (R1), which poses a potential health and safety risk to resident 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:Desaree Perera
LICENSING EVALUATOR NAME:Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2021


LIC809 (FAS) - (06/04)
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