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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608349
Report Date: 12/06/2021
Date Signed: 12/06/2021 01:05:45 PM

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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ABBEY ROAD VILLAFACILITY NUMBER:
197608349
ADMINISTRATOR:MARINE KARAPETIANFACILITY TYPE:
740
ADDRESS:14132 HUBBARD STREETTELEPHONE:
(818) 837-0077
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY:78CENSUS: 51DATE:
12/06/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Marine KarapetianTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tuesday Cabiness, conducted a case management, in conjunction to a complaint investigation, with control number 31-AS-20211130101037. During the investigation, it was revealed that an incident occurred at the facility on 11/28/2021, between (2) residents, and the facility did not submit an special incident report (SIR) to Licensing. The Administrator Marine could not provide an explanation as to why the SIR was sent to Licensing. LPA expressed the concern of not reporting incidents to Licensing. At conclusion of the complaint visit, LPA received the SIR via email by the Administrator. This is a potential health and safety risk to residents in care.

Citation issued, POC cleared and copy of reports and letters emailed to Administrator Marine Karapetian.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021
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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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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ABBEY ROAD VILLA
FACILITY NUMBER: 197608349
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/06/2021
Section Cited

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Reporting Requirements. (b) during the operation of the facility...(1) below, a report shall be made to the licensing agency within...seven days following the occurrence of such event... (D) Any injury to any client..
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This requirement was not met evidenced by; based on the investigation; R2 attempted to chase R1, causing R1 to fall. The incident was not reported to Licensing. This is a potential health and safety risk to clients in care.






Any injury to any client which requires medical treatment.
Narrative: This requirement was not met evidenced by; based on the investigation conducted by Investigator Spindola and documentation received by LPA, C1 sustained injuries; staff applied a medical ointment, and staff failed to report the incident to Licensing in a timely manner. This is a potential health and safety risk to clients 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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2021
LIC809 (FAS) - (06/04)
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