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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608711
Report Date: 11/20/2020
Date Signed: 11/20/2020 05:25:28 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:FOOTHILL RETIREMENT CARE HOMEFACILITY NUMBER:
197608711
ADMINISTRATOR:JINA MALEKSARKISSIANSFACILITY TYPE:
740
ADDRESS:6720 SAINT ESTEBAN STREETTELEPHONE:
(818) 353-3350
CITY:TUJUNGASTATE: CAZIP CODE:
91042
CAPACITY:72CENSUS: 49DATE:
11/20/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jina Maleksarkissians TIME COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA) Martina Berry conducted a Case Management incident Visit at 10:00 AM. Due to the situation surrounding COVID-19 and to implement mitigation measures, this visit was conducted virtually via Microsoft Teams. The LPA met with Administrator Jina Maleksarkissians and explained the reason for the visit.

The Woodland Hills Regional Office received an incident report on 11/19/20 to report an incident that occurred on 11/17/20 involving facility staff (S1) and a resident (R1). The incident report reported alleged abuse to R1 by S1. During the visit, The LPA conducted a facility tour. The LPA interviewed the administrator, staff (S2, S3, and S4) and residents (R2, R3, and R4). The administrator stated that S1 is no longer providing direct services to R1 pending investigation results. The incident was cross reported to the local police department and Long-Term Care Ombudsman. The LPA requested documentation including LIC 500, Resident file, and SOC 341. Additional information is needed regarding this incident.

An exit interview was conducted with Administrator Jina Maleksarkissians. A copy of this report was provided to the administrator via email for signature.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (8185964342
LICENSING EVALUATOR NAME: Martina BerryTELEPHONE: (661) 361-6007
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2020
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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