197608678-8-12-2024-31-AS-HRAI-D83SVB-20240812141228

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608678
Report Date: 08/12/2024
Date Signed: 08/12/2024 02:13:11 PM

Document Has Been Signed on 08/12/2024 02:13 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	HARTLAND CARE, INC.		FACILITY NUMBER:	197608678
ADMINISTRATOR:	ANI MAKARYAN		FACILITY TYPE:	740
ADDRESS:	8224 ZELZAH AVENUE		TELEPHONE:	(818) 697-5363
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY:	6	CENSUS: 5	DATE:	08/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Dianna Makaryan, Administrator		TIME COMPLETED:	02:45 PM

NARRATIVE

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At 09:40 AM, Licensing Program Analyst (LPA) Huma Rahimi, conducted an unannounced annual visit. LPA met with staff, Hasmik Mandlyan,and the Administrator was contacted. LPA disclosed the reason for the visit and the Administrator, Dianna Makaryan and the Administrator arrived at 10:15 AM. LPA and Administrator toured the facility inside and out.

The facility is a single story building with four (4) bedrooms, two (2) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for six (6) nonambulatiory residents, of which one (1) may be bedridden in Bedroom # one (1). The facility serves residents with dementia. Approved hospice waivers for six (6). The facility uses surveillance cameras on the interior and exterior.

Kitchen: At approximately, 10:15 AM LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps observed to be locked in a kitchen cabinet. A fully charged fire extinguisher hung near the kitchen purchased on 02/14/2024.

Laundry Room: At 10:17 AM, LPA observed that the cleaning solutions were locked in the laundry room, located next to the kitchen. A washer and dryer in good condition and LPA observed both were running washing and drying cloths.

Medications: At approximately, 10:20 AM LPA observed medications are centrally stored and were locked near the dining room cabinet. In Room # three (3), LPA observed anti-itch ointment accessible to residents in care.

Bedrooms: The facility has four (4) bedrooms. Two (2) are private and two (2) are shared. All bedrooms contained a nightstand, storage, and bed with adequate bedding. All furnishings were clean and in good condition. Bedroom four (4) is vacant.

Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HARTLAND CARE, INC.	FACILITY NUMBER: 197608678
	VISIT DATE: 08/12/2024

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Bathrooms: The facility has two (2) bathrooms. One of the bathrooms is designated for staff and the other for residents. 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. At 10:26 AM, hot water temperature measured at 114.3°F. A closet in the hallway contained a sufficient supply of linens.

Common Areas: The facility maintains a comfortable temperature at 78°F. The living room and dining area appeared clean and were properly furnished. The living room has a television, comfortable furniture. No obstructions and or tripping hazards throughout the facility.

Outside areas: At approximately, 10:30 AM, LPA toured the outside area of the facility. 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.

The garage is attached to the home without an excess from the home and is kept locked inaccessible to residents.

Smoke detectors/carbon monoxide. At 11:20 AM, LPA tested the dual-function smoke and carbon monoxide detector to be operational. Two (2) out of two (2) detectors were functioned during the test, and an additional verbal alert sounded.

Between 11:45 AM to 1:20 PM, LPA reviewed records of five (5) residents and two (2) staff. LPA observed that five (5) out of five (5) residents files were incomplete or not updated. Additionally, LPA observed that two (2) out of (2) staff required training were not updated or completed.

Administrative: LPA collected Certificate of Liability Insurance, and LIC500.

Citations were issued. Appeal rights explained.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/12/2024 02:13 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HARTLAND CARE, INC.	FACILITY NUMBER: 197608678
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(a)

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in five out of five residents files missing documents or not updated which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/19/2024
	Plan of Correction
1 2 3 4	The Administrator will review regulation 87506 and send an email to LPA Rahimi confirming the Administrator did review the regulation. License/Administrator will complete files for all residents. Once completed licensee/administrator will submit a complete files for the residents to LPA by POC due date.

Type B

Section Cited

HSC

1569.626(a)(2)

(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (2) Eight hours of in-service training per year on the subject of serving residents with dementia. This training shall be developed in consultation with individuals or organizations with specific expertise in dementia care or by an outside source with expertise in dementia care. In formulating and providing this training, reference may be made to written materials and literature on dementia and the care and treatment of persons with dementia. This training requirement may be satisfied in one day or over a period of time. This training requirement may be provided at the facility or offsite and may include a combination of observation and practical application. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	(b) Based on record review, the licensee did not comply with the section cited above in [2] out of [2] missing training records for staff and had incomplete personnel records. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/19/2024
	Plan of Correction
1 2 3 4	Licensee agreed to hire a licensed vendor and provide training to all staff members. Copy of proof will be submitted to LPA by POC 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: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/12/2024 02:13 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HARTLAND CARE, INC.	FACILITY NUMBER: 197608678
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

(f) The following shall be stored inaccessible to residents with dementia: (f) The following shall be stored inaccessible to residents with dementia: (f) The following shall be stored inaccessible to residents with dementia: (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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in three out of three medication storage, Clobetasol Propionate Cream USP 0.05%, Permethrin Cream 5%, and Clindamycin Phosphate Topical solution USP 1% were unlocked and accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/14/2024
	Plan of Correction
1 2 3 4	Administrator locked medications and agreed to provide training with a vendor. Administrator will submit the schedule of the training with the vendor and the certificates upon completion of the training to LPA Rahimi, by the POC due date.

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: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024

LIC809 (FAS) - (06/04)

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