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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608711
Report Date: 11/04/2021
Date Signed: 11/04/2021 03:55:04 PM

Document Has Been Signed on 11/04/2021 03:55 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: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: 40DATE:
11/04/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Roy ManasanTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Pitz generated this Case Management report in order to address a deficiency that arose during the investigation of complaint # 31-AS-20200922155620.

On 10/01/21 LPA requested a series of financial documents by email for the purpose of referring the facility to an audit. On 10/29/21 the facility administrator informed LPA by phone that the facility's headquarters did not believe they needed to release this documentation.

Report reviewed, signed and delivered. Exit interview conducted, deficiencies on 809D page.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Alexander Pitz
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2021
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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Document Has Been Signed on 11/04/2021 03:55 PM - It Cannot Be Edited


Created By: Alexander Pitz On 11/04/2021 at 08:00 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: FOOTHILL RETIREMENT CARE HOME
FACILITY NUMBER: 197608711

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/30/2021
Section Cited
CCR
87755(c)

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87755(c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the requirements in Sections 87412(f), 87506(d), and 87508(b).
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Administrator stated that he understands the cited regulation and intends to abide by it. Administrator will comply with all legal requests for necessary records from Community Care Licensing.
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This requirement is not met as evidenced by:

Based on an interview with the administrator on 10/29/21, the facility did not agree to release pertinent facility records which poses a potential risk to the residents in care.
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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:Eva Miller
LICENSING EVALUATOR NAME:Alexander Pitz
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2021


LIC809 (FAS) - (06/04)
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