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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608459
Report Date: 08/30/2024
Date Signed: 08/30/2024 02:36:30 PM


Document Has Been Signed on 08/30/2024 02:36 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:EMVY BOARD AND CARE FACILITYFACILITY NUMBER:
197608459
ADMINISTRATOR:EMMA KOCHINYANFACILITY TYPE:
740
ADDRESS:14164 COHASSET STREETTELEPHONE:
(818) 947-1711
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY:6CENSUS: 5DATE:
08/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:31 AM
MET WITH:Emma KochinyanTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:31 AM. LPA met with facility staff who contacted the facility administrator Emma Kochinyan via telephone call. Facility administrator arrived to the facility at 09:40 AM Entrance interview conducted and the reason for the visit was explained.

Beginning at 09:40 AM, the LPA, along with facility administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured drawer to contain knives and other sharp objects. The LPA observed the fire extinguisher to be fully charged and purchased on 03/08/2024. LPA observed a secured cabinet and a secured box located in the refrigerator to contain resident medication.

BEDROOMS: There are three (3) bedrooms in the facility; all three (3) are designated for resident use. LPA and facility administrator toured all three (3) resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedroom number three (#3) contains a direct exit to the backyard. One resident bed was observed to contain full bed rails. Auditory alarms were observed on facility exits and were functional at the time of the visit.

Report Continued on LIC 809-C
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024
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 9


Document Has Been Signed on 08/30/2024 02:36 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: EMVY BOARD AND CARE FACILITY
FACILITY NUMBER: 197608459

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2024

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
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Based on observation, the licensee did not comply with the section cited above as an unsecured box cutter was observed in an unlocked closet which posed an immediate health and safety risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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Administrator secured the box cutter at the time of the visit. POC cleared.
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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/30/2024 02:36 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: EMVY BOARD AND CARE FACILITY
FACILITY NUMBER: 197608459

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as one (1) staff member lacked the required 20 hour annual training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2024
Plan of Correction
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Administrator will submit the following to CCL no later than POC due date. Proof of completed trainings, proof of completed in-service trainings, or proof of enrollment in required trainings for the identified employee.
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as two (2) of two (2) resident centrally stored medication record sheets were missing perscribed medications which poses a potential health and safety risk to persons in care.
POC Due Date: 09/06/2024
Plan of Correction
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Administrator will submit proof of updated centrally stored medication record sheets for the two (2) identified residents to CCL no later than POC due date.
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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/30/2024 02:36 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: EMVY BOARD AND CARE FACILITY
FACILITY NUMBER: 197608459

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as one (1) resident has full bed rails but does not have a physician's order for them which poses a potential personal rights risk to persons in care.
POC Due Date: 09/06/2024
Plan of Correction
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Administrator will submit either, proof of physician's orders for full bed rails or proof that full bed rails have been removed to CCL no later than POC due date.
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as one (1) resident who is diagnosed with dementia lacked a physician's report dated within the last year which poses a potential health risk to persons in care.
POC Due Date: 09/06/2024
Plan of Correction
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Administrator will submit proof of an updated physician''s report for the identified resident to CCL no later than POC due date.
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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/30/2024 02:36 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: EMVY BOARD AND CARE FACILITY
FACILITY NUMBER: 197608459

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on observation and record review, the licensee did not comply with the section cited above as one (1) resident was identified to be at risk if allowed access to personal hygiene items and personal hygiene items were observed unsecured throughout the facility which poses a potential health and safety risk to persons in care.
POC Due Date: 09/06/2024
Plan of Correction
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Licensee will submit proof to CCL no later than POC due date that all hygiene items throughout the facility have been appropriately secured.
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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024
LIC809 (FAS) - (06/04)
Page: 5 of 9


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: EMVY BOARD AND CARE FACILITY
FACILITY NUMBER: 197608459
VISIT DATE: 08/30/2024
NARRATIVE
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BATHROOMS: There are two (2) bathrooms at the facility. Both bathrooms were observed to be clean and in good repair and all were equipped with nonskid surfaces. Grab bars were observed in all showers and near all toilets, all were properly secured. The water temperature was measured between 106.5 and 112.3 degrees Fahrenheit, which is in compliance with regulation. Both bathrooms were observed to contain unsecured personal grooming supplies for resident use.


COMMON AREAS: This includes the living room, dining room, and a seating area. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contains an appropriately screened fireplace. Smoke detectors and carbon monoxide detectors were tested at 12:00 p.m. and were functional at the time of the visit. The dining room was observed to be clean and contains adequate seating for resident use. The seating room was observed to be clean with adequate seating and an appropriately screened fireplace. A closet attached to the seating room was observed to be unsecured and contained paint, painting supplies, and a box cutter.

OUTDOOR SPACE/GARAGE: The facility has two (2) emergency exit gates, LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. Ramps were observed leading to the backyard from the dining room and bedroom number three (#3). All rails were secure and in good repair. LPA observed an extra refrigerator on the outdoor patio to contain extra food supplies. The garage was observed to be secured and contains a washer and dryer, cleaning chemicals, and extra care supplies. The garage contains adequate emergency food and water supplies.

RECORD REVIEW: Record review began at 10:13 a.m. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, TB tests, consent forms, and personal rights. Three (3) staff files were reviewed. All staff files contained the required documents. One (1) staff file reviewed was missing the required twenty (20) hours of annual training. Five (5) resident files were reviewed. All resident files reviewed contained all required documentation. Review of resident one’s (R1s) file revealed that they did not have a physician’s order for full bed rails.
Report Continued on LIC 809-C
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024
LIC809 (FAS) - (06/04)
Page: 8 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: EMVY BOARD AND CARE FACILITY
FACILITY NUMBER: 197608459
VISIT DATE: 08/30/2024
NARRATIVE
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MEDICATION REVIEW: Medication review began at 11:33 a.m. Medications are stored centrally and securely in a cabinet in the kitchen. Medications for two (2) residents were observed. Two (2) of two (2) centrally stored medication record sheets were missing some of the resident’s prescribed medications.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the
facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Last emergency disaster drill was conducted on 06/03/2024. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated quarterly.

INTERVIEWS: LPA interviewed one (1) staff and two (2) residents. All residents interviewed stated that the food was of good quality and is provided in sufficient amounts. All residents stated that staff treat them very well and are attentive to their needs. No residents interviewed had concerns with the facility. The staff member interviewed was knowledgeable on their roles and responsibilities, resident rights, the different forms of abuse and the appropriate reporting procedures for suspected abuse.

During today’s visit LPA obtained a copy of the facility’s resident roster and liability insurance.

The Pursuant to Title 22 of the CA Code of Regulations, and the Health and Safety Code, the following deficiencies were cited (refer to LIC 809-Ds):



Citations were issued. Exit interview was conducted. today's report, and appeal rights were reviewed and issued.
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024
LIC809 (FAS) - (06/04)
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