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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608678
Report Date: 08/12/2021
Date Signed: 08/12/2021 04:10:04 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:HARTLAND CARE, INC.FACILITY NUMBER:
197608678
ADMINISTRATOR:ANI MAKARYANFACILITY TYPE:
740
ADDRESS:8224 ZELZAH AVENUETELEPHONE:
(818) 697-5363
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:6CENSUS: 5DATE:
08/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:14 PM
MET WITH:Polina MabarianTIME COMPLETED:
04:20 PM
NARRATIVE
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At 1:14pm Licensing Program Analysts (LPAs) Angela Panushkina, Melissa Ruiz and Licensing Program Manager (LPM), Nichelle Gylliard conducted an unannounced annual inspection at the above facility. Team met with the caregiver, Polina Mabarian, who granted access to home. This is a 4 bedroom, 1 bathroom, single story family residence that includes a living room, dining area, kitchen, laundry room and attached garage. At approximately, 1:25pm LPA spoke with the Administrator Diana Makaryan over the phone and received a consent to start a tour of the entire facility with the Polina and be able to ask any questions.
Infection control: LPA Panushkina reviewed facility mitigation plan (approved on 04/20/21) to make sure licensee was following current infection control recommendations. Upon arrival the team did not observe any COVID-19 signs being posted on the front door. LPA team was screened by the staff, however, the team was not asked any infection control questions. The team had to prompt and guide staff through the screening process.
Food Inspection: At 1:30pm the team conducted a food inspection tour an found the following: The facility does have enough sufficient supply of 2 days perishable foods and one week of non-perishable foods. The kitchen knives were observed to be accessible to residents in care.
Bedrooms: There are four bedrooms designated for residents' use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Auditory alarms are in poor repair on a back door. The facility has Dementia residents in care and this poses a potential health and safety risk

There is one carbon monoxide detector in the kitchen area. Smoke detectors were checked and are hardwired throughout the facility. Smoke detectors and carbon monoxide are observed to be operational.

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SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021
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 4
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: HARTLAND CARE, INC.
FACILITY NUMBER: 197608678
VISIT DATE: 08/12/2021
NARRATIVE
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Bathrooms: At 1:40pm LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured at 111.6F. LPA observed appropriate grab bar and had non-skid mat. LPA observed appropriate hand washing signs posted in each bathroom. Trash can in bathrooms need lids to protect from cross contamination.
Common Areas: The facility maintains a comfortable temperature at 75F. The living room and dining area appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. There is a fire extinguisher in the kitchen which was observed to be full.
Laundry Area: At approximately, 1:32pm LPA team observed the laundry door unlocked and chemicals and cleaning supplies were accessible to residents in care
Surrounding Grounds: LPA toured the outside area of the facility. LPA observed various items stored in the backyard which need to be removed and placed in a storage. There are no bodies of water. Gate was unlocked and easily accessible to open. There is an appropriate shaded and seating area for residents outside.
The garage is attached to the home without an excess from the home and is kept locked inaccessible to residents.
Medications: At approximately, 1:25pm LPA team observed medications are centrally stored, however the cabinet was not locked and accessible to residents.
Administrative: LPA collected Certificate of Liability Insurance, Administrator Certificate and LIC.500. Annual fees are current. Staff on duty has worked for about one months on a relief basis, once a week, and has not been cleared nor associated with the facility.

Deficiencies issued per Title 22.

Appeal rights issued.

Exit interview

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: HARTLAND CARE, INC.
FACILITY NUMBER: 197608678
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(a)
87355 Criminal Record Clearance

(a) The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code section 1569.17 and shall have the authority to approve or deny a facility license, or employment, residence, or presence in the facility, based upon the results of such review.

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 in which staff member was not associated with the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/14/2021
Plan of Correction
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Administrator will ensure staff member will go do livescan fingerprinting and provide proof and it will be e-mailed to LPA by the POC date.
Type A
Section Cited
CCR
87355(e)(3)

87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(3) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at 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 in which a staff did not get an exemption clearance prior to working in the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/14/2021
Plan of Correction
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Administrator will submit LIC508, LIC9188 and a copy of a Driver License. Staff shall no return to work until the exepmtion is approved.
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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: HARTLAND CARE, INC.
FACILITY NUMBER: 197608678
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)(2)

87705 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).
(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

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. Team observed the sharp knives and medication to be accessible to residents in care.
POC Due Date: 08/14/2021
Plan of Correction
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The Administrator has agreed to lock all the sharps and medication. This part of the plan of correction was met during the visit. The Administrator has agreed to provide training to all staff on the importance of maintaining medications inaccessible and keep all sharp items inaccessible. The administator shall submit staff sign in sheet with the topic and the training material.
Type A
Section Cited
CCR
8746.1(a)(2)

87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.



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. The licensee failed to follow the infection control protocol on screening procedures. Staff were not familiar with screening procedures, none of the thermometers were operating properly and no symptom screening questions have been asked, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/14/2021
Plan of Correction
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Licensee agreed to train all staff on Mitigation Plan and Infection Control which includes screening. Staff sign-in sheet and training materials shall be e-mailed to LPA (Angela.Panushkina@dss.ca.gov)
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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4