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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608678
Report Date: 08/29/2022
Date Signed: 08/29/2022 12:45:32 PM


Document Has Been Signed on 08/29/2022 12:45 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, 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:
08/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Sirvard HarutyunyanTIME COMPLETED:
12:55 PM
NARRATIVE
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At 10:30 a.m. on 08/29/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with staff and disclosed the reason for the visit. LPA and staff toured the facility inside and out.

The facility was last visited on 06/15/2022 for a complaint visit. It is a single story building with 4 bedrooms, 2 bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for 6 nonambulatiory residents, of which 1 may be bedridden in Bedroom #1. The facility serves residents with dementia. Approved hospice waivers for 2. The facility uses surveillance cameras on the interior and exterior.

On the front door hung a sign regarding the facility’s visitation policy. LPA was not screened for infectious disease upon entry. The screening station contained digital thermometer, masks, hand sanitizer, and visitor log. The facility did not track temperature, symptoms, and vaccination statuses of all visitors. Facility postings included Emergency Disaster Plan, facility license, administrator certificate, facility sketch, confidential complaints contact, personal rights, and COVID policies and precautions.

The facility has 4 bedrooms. 2 are private. 2 are shared. All bedrooms contained a nightstand, storage, and bed with adequate bedding. All furnishings were clean and in good condition. At approximately 10:57 a.m. staff confirmed that the resident in Bedroom #1 had passed away about one month ago. Bedrooms #2 and #4 are shared rooms. In both bedrooms, the beds were less than 6 feet apart and did not provide social distance for residents. In Bedroom #3 and Bedroom #4, all 3 residents were observed in bed with full bed rails.

The facility has 2 bathrooms. The bathroom designated for residents contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. A closet in the hallway contained a sufficient supply of fresh linens. LPA observed an adequate supply of perishable and non-perishable food in the kitchen. Appliances were functional and clean. Sharps were locked below the counter, and cleaning solutions were locked in the laundry room. A washer and dryer in good condition were also located in the laundry room.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2022
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: HARTLAND CARE, INC.
FACILITY NUMBER: 197608678
VISIT DATE: 08/29/2022
NARRATIVE
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 Medications were locked near the dining room. A fully charged fire extinguisher hung near the kitchen. Walls, floors, ceilings, windows, and blinds were clean and in good repair. At 10:58 a.m. LPA tested the dual-function smoke and carbon monoxide detector to be operational. 2 out of 2 detectors functioned during the test, and an additional verbal alert sounded. At 11:00 a.m. LPA measured the room temperature to be 78 degrees Fahrenheit. LPA observed a covered patio area outside with furniture in good repair. The emergency exit was unlocked with an inward facing latch. Emergency exit paths were free from debris.

At approximately 11:30 a.m. LPA conducted a facility file review. No death report was sent for the resident in Bedroom #1. Furthermore, the staff working was not associated to the facility and could not recall obtaining a criminal background clearance. An interview at 11:35 a.m. with staff and residents confirmed that the 3 residents in Bedrooms #3 and #4 are receiving hospice services, and one resident in Bedroom #4 is bedridden. LPA cited the deficiencies on the LIC 809-D page.

Exit interview conducted. Copy of report, appeal rights, and citations issued.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/29/2022 12:45 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
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: 08/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)
87470 (c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review, the licensee did not comply with the section cited above in 1 out of 1 Infection Control Plan which poses a potential Health, Safety, or Personal Rights risk to residents in care.
POC Due Date: 09/29/2022
Plan of Correction
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Licensee will submit an Infection Control Plan by the POC due date.
Type B
Section Cited
CCR
87470(c)(1)(F)
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following: (F) Staff shall demonstrate knowledge of and skill in infection control, as appropriate to the job assigned and as evidenced by safe and effective job performance.

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 by not screening 1 out of 1 visitors which poses a potential Health, Safety or Personal Rights risk to persons in care.
POC Due Date: 09/29/2022
Plan of Correction
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Licensee to provide training for the section cited above to all staff. Licensee to record temperature, symptoms, and vaccination status in visitor log. Licensee to submit proof of completion by the 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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 08/29/2022 12:45 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
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: 08/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
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: (1) Obtain a California clearance or a criminal record exemption as required by the Department.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review, the licensee did not comply with the section cited above in 1 out of 1 employees which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2022
Plan of Correction
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Licensee will send all staff to obtain fingerprints and criminal background clearances to work in the facilty. Licensee will associate all staff to the facility by POC due date.
Type A
Section Cited
HSC
1569.72(c)
§1569.72 Residents requiring skilled nursing or intermediate care; bedridden residents (c) ...bedridden persons may be admitted to, and remain in, residential care facilities for the elderly that secure and maintain an appropriate fire clearance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews the licensee did not comply with the section cited above in 1 out of 1 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2022
Plan of Correction
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Licensee to relocate the bedridden resident in Bedroom #4 to Bedroom #1 and provide proof by the 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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 08/29/2022 12:45 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
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: 08/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(1)(A)
87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below...
(A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above in 1 out of 1 reports which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2022
Plan of Correction
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Licensee to submit a Death Report for the resident who most recently resided in Bedroom #1 by the POC due date.
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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 08/29/2022 12:45 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
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: 08/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87633(a)(1)
87633 Hospice Care of Terminally Ill Residents (a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility when all of the following conditions are met: (1) The licensee has received a hospice care waiver from the department.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 3 residents receiving hospice services which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2022
Plan of Correction
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Licensee to submit hospice care plans for all three residents receiving hospice services and request an additional hospice waiver by the POC due date.
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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2022
LIC809 (FAS) - (06/04)
Page: 6 of 6