197608345-4-14-2023-29-AS-CYEE-CQW26Q-20230414170730

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608345
Report Date: 04/14/2023
Date Signed: 04/14/2023 05:09:44 PM

Document Has Been Signed on 04/14/2023 05:09 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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	VICTORY HOME		FACILITY NUMBER:	197608345
ADMINISTRATOR:	ANDREW AKHPARIAN		FACILITY TYPE:	735
ADDRESS:	6228 BABCOCK AVE		TELEPHONE:	(818) 585-0095
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY: 4		CENSUS: 4	DATE:	04/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:01 AM
MET WITH:	Andrew Akhparian, Administrator		TIME COMPLETED:	05:30 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) Christine Yee conducted an unannounced required Annual Inspection and was let into the home by Marika Petevotyan, Staff. Diana Gevorgyan, Administrator, was contacted by staff but was unable to conduct the visit until later in the day. Andrew Akhparian, Administrator, he arrived at 9:38am to conduct the visit. The reason for today's visit was explained. The home is a single storey family home consisting of a living room, dining room, kitchen, family room, 5 bedrooms of which two is designated for living-in staff and 3 full bathrooms. Located in the backyard is a swimming pool which is surrounded by a 5 feet rod iron fence. The home is vendorized by the North Los Angeles Regional Center. Today's annual inspection was conducted using the complete CARE tool. The following were observed during the physical tour of the facility: The resident bedrooms had the required furniture The required linens were observed in all the resident bedrooms except in the second bedroom adjacent to the common bathroom. All the beddings were removed for laundry and there was insufficient bed linens to allow for changing. The night stand in the shared bedroom(third room) was observed with a broken continued on LIC9099-C

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

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 6

Document Has Been Signed on 04/14/2023 05:09 PM - It Cannot Be Edited

Created By: Christine Yee On 04/14/2023 at 03:03 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: VICTORY HOME	FACILITY NUMBER: 197608345
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

85076(d)(1)

Food Service

(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises. 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 in 1 out of 1 cases to ensure that the facility had sufficient supply of non-perishable foods maintained on the premises and this poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/15/2023
	Plan of Correction
1 2 3 4	The Licensee will ensure that the required quantity of food required by Title 22 are maintained at the facility at all times.. Deficiency was corrected at the time of the visit - Administrator made a food run

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:

Jeralyn Ann Pfannenstiel

LICENSING EVALUATOR NAME:

Christine Yee

LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC809 (FAS) - (06/04)

Page: 2 of 6

Document Has Been Signed on 04/14/2023 05:09 PM - It Cannot Be Edited

Created By: Christine Yee On 04/14/2023 at 03:03 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: VICTORY HOME	FACILITY NUMBER: 197608345
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. 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 in 1 out of 1 cases to ensure that the facility grounds were kept clean and well maintained from debris and this poses a potential health, safety or personal rights risk to persons in care. LPA observed discarded open house placards, open house placards, old plastic buckets, bricks, dried twigss, unrolled hoses and old wood.
	POC Due Date: 04/21/2023
	Plan of Correction
1 2 3 4	The licensee will ensure that a general cleaning is conducted of the facility premises to ensure that all discarded items, such as placards, plastic buckets, bricks broom sticks, mops are either discarded or stored away as necessary. Licensee will self certify that the correction has been made.

Type B

Section Cited

CCR

80088(f)(1)

Fixtures, Furniture, Equipment, and Supplies

(f) Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents. (1) All containers, including movable bins, used for storage of solid wastes shall have tight-fitting covers kept on the containers; shall be in good repair, shall be leakproof and rodent-proof. 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 by not ensuring that the the solid waste in the large trash containers are tightly sealed which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/21/2023
	Plan of Correction
1 2 3 4	The Licensee will ensure that all receptacles used for storage of solid waste are covered at all times. Licensee will self certify that the correction has been made by 4/21/23

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:

Jeralyn Ann Pfannenstiel

LICENSING EVALUATOR NAME:

Christine Yee

LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VICTORY HOME	FACILITY NUMBER: 197608345
	VISIT DATE: 04/14/2023

NARRATIVE

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drawer
All the bedrooms have the appropriate window dressing.
The living room, dining room and family room had the appropriate furniture
The kitchen appliances were operational
The converted garage is used as an office and bedroom for staff.
The water temperature taken in the common bathroom tested 108 degrees Fahrenheit and the water in the private bathroom tested 111.7 degrees Fahrenheit. Non-skid mats were observed.
Smoke detectors located in the resident bedrooms were all tested and were operational
The only carbon monoxide detector located at the end of the hall way was tested and was operational
There were 2 fire extinguishers - one located in the kitchen and one in the laundry room- were purchased in December 2022.
Night lights were observed in the hallway
The washer and dryer in the laundry room was operational
Sufficient perishable foods for 2 days was observed and insufficient non-perishable foods were observed.
The front yard was observed to be well maintained and has a covered patio.
The backyard has a pool surrounded by a 5 feet rod iron fence and a covered patio equipped with a table and chairs.. Also observed in the back were trash cans with open lids, bags/open containers with recyclable bottles and cans.
Along the right side of the house were a extra refrigerator and 2 storage cabinets, and littered with open house placards, bricks, dried twigs, old wood, plastic buckets and unrolled hoses.

Continued on LIC9099-C

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC809 (FAS) - (06/04)

Page: 4 of 6

Document Has Been Signed on 04/14/2023 05:09 PM - It Cannot Be Edited

Created By: Christine Yee On 04/14/2023 at 04:26 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: VICTORY HOME	FACILITY NUMBER: 197608345
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85088(a)(4)(A)

85088 Fixtures, Furniture, Equipment and Supplies. (a) In addition to Section 80088, as a condition of licensure, the following shall apply. (4)Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; rubber or plastic sheeting, when necessary .......(A) The quantity of linen provided shall permit changing the linen at least once each week or more often when necessary to ensure that clean linen is in use by clients at all times. This requirement is not met as evidenced by: there is insufficient bed linens to allow for weekly changing
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above iby ensuring that there is sufficient lines to allow for weekly changing or as needed, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/21/2023
	Plan of Correction
1 2 3 4	The licensee will purchase additional linens - bedding and towels to allow the weekly change of bedding and towels or as needed. Provided copy of receipt by POC date of 4/21/23.

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:

Jeralyn Ann Pfannenstiel

LICENSING EVALUATOR NAME:

Christine Yee

LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC809 (FAS) - (06/04)

Page: 6 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VICTORY HOME	FACILITY NUMBER: 197608345
	VISIT DATE: 04/14/2023

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 26 27 28 29 30 31 32	Deficiencies were cited under California Code of Regulations, Title 22, Division 6, Chapter 1 and Chapter 5. Exit interview was conducted, Appeals Rights discussed and a copy of the report was provided.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC809 (FAS) - (06/04)

Page: 5 of 6