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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608797
Report Date: 05/12/2022
Date Signed: 05/12/2022 05:20:42 PM


Document Has Been Signed on 05/12/2022 05:20 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:DREAM HOME BOARD AND CAREFACILITY NUMBER:
197608797
ADMINISTRATOR:KARINE ASLANYANFACILITY TYPE:
740
ADDRESS:22812 SATICOY STREETTELEPHONE:
(818) 370-9117
CITY:WEST HILLSSTATE: CAZIP CODE:
91304
CAPACITY:6CENSUS: 4DATE:
05/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Leila KreleTIME COMPLETED:
05:20 PM
NARRATIVE
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At approximately 1:55 p.m. on 05/12/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff #1 (S1) and disclosed the reason for the visit. At approximately 2:10 p.m. S1 called Administrator (S2). LPA spoke with S2 and disclosed the reason for the visit. S2 stated that due to an emergency, they could not come to the facility today. LPA informed S2 that an administrator or designated representative must be available at the facility at all times. S2 requested the inspection be rescheduled for Monday. LPA stated the inspection must be conducted today. LPA asked if S1 could sign in S2’s absence. S2 refused. LPA and S1 toured the facility inside and out.

The facility was last visited on 05/24/2019 for a an annual inspection. It is a single story building with 5 bedrooms, 3 bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for 6 nonambulatory residents, of which 1 may be bedridden. The facility serves a resident with cognitive impairment. Approved hospice waivers for 2. The facility uses surveillance cameras inside and out.

Entry: LPA observed a maintained front yard. Once inside, LPA observed postings for confidential complaints, resident councils, resident rights, COVID policies, facility license, and two Administrator certificates. The certificates expired on 05/09/2020 and 06/21/2020. At 3:03 p.m. LPA conducted a record review of current and pending administrator certificates at https://cdss.ca.gov/inforesources/community-care/administrator-certification/administrator-information/active-certificates. LPA did not see either administrator listed. LPA called a secondary Administrator (S3) at 4:54 p.m. S3 stated all documents were submitted one year ago. LPA will confirm proof of documentation on 05/16/2022.

Screening: LPA was not screened for infectious disease upon entry. The facility did not have a screening station. S1 and staff #4 (S4) were observed without a mask for the duration of the inspection. The facility does not have a screening station.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
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: DREAM HOME BOARD AND CARE
FACILITY NUMBER: 197608797
VISIT DATE: 05/12/2022
NARRATIVE
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Bedrooms: The facility has 5 bedrooms. 4 are private and 1 is shared. All bedrooms contained a chair, nightstand, storage, and bed with adequate bedding. All furnishings were clean and in good condition. Bedroom #3 contained a resident using oxygen. A sign indicating oxygen is in use was posted on the bedroom door. At approximately 2:30 p.m. LPA observed 5 medication bottles on the bedside table in Bedroom #5. S1 explained they were there for the resident’s preference. S1 also explained that some pills were Russian. LPA observed a clear vial with yellow pills inside and non-English writing on the label. LPA explained that all medication must be locked.

Bathrooms: The facility has 3 bathrooms. All bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash cans, devices with grab bars near the toilet and shower, and a non-skid mat in the showers. At approximately 2:20 p.m. LPA observed 4 creams in the Bathroom #2. Staff explained the creams were for itchiness. At 2:51 p.m. LPA measured the water temperature in Bathroom #2 to be 106.6 degrees Fahrenheit.

Kitchen: LPA observed an adequate supply of perishable and non-perishable food. All surfaces were clean. Sharp objects were locked under the counter.

Laundry: The laundry room was locked with an “Employees Only” sign. Bleach and detergent were sitting next to a washer and dryer in good condition. The garage was accessible through the laundry room and was free of hazards.

Common Areas: Walls, floors, ceilings, windows, and screens were clean and in good repair. Medication was locked near the kitchen and dining room. At 2:21 p.m. LPA measured the indoor temperature to be 73 degrees Fahrenheit.

Safety: All emergency exit paths were free from obstructions. Exterior exit gates on the east and west side were locked. At approximately 2:35 p.m. LPA asked staff why the exit gates were locked. Staff stated R1 likes to wander. S1 stated they do not have the key to unlock the gates. Emergency Disaster Plan posted at the entrance. LPA observed a smoke detector near the ceiling at the main entrance. LPA will test smoke and carbon monoxide detectors during the Annual – Continuation visit.

Outdoor areas: LPA observed a covered patio with furniture and workout equipment. A shed at the rear of the facility was locked.

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

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC809 (FAS) - (06/04)
Page: 2 of 7
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: DREAM HOME BOARD AND CARE
FACILITY NUMBER: 197608797
VISIT DATE: 05/12/2022
NARRATIVE
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At 2:44 p.m. LPA observed Resident #1 (R1) ask S1 to go outside. S1 replied, “You’re not going outside today because you were outside today earlier”. S1 then sat with R1 and watched television in the living room.

At 2:59 p.m. staff #4 (S4) entered the facility at the main entrance. S4 was not wearing a mask and was not screened for infectious disease.

At 3:37 p.m. R1 walked out of a side door. S1 said to R1, “No, close door. Please, I don’t have key. Not today" S4 and S1 followed R1 outside. S4 explained to LPA that R1 is agitated. R1 was overheard cursing at S4.

At approximately 4:19 p.m. 3 family members of a resident visited the facility without being screened or wearing masks. One family member stated, "We tried to call, but no one ever answers the phone".

Administrator refused to sign all documents.

During today's inspection, the facility was in not compliance with Title 22 regulations. Citations issued on LIC 809-D page.

Exit interview conducted. Copy of report and appeal rights provided.

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

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 05/12/2022 05:20 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: DREAM HOME BOARD AND CARE
FACILITY NUMBER: 197608797

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/10/2022
Section Cited

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87405(a) Administrator - Qualifications and Duties - When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this
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section. This requirement is not met as evidenced by:
Based on observation and interview, the licensee did not comply with the above section. 2 out of 2 administrators were not present. This poses a potential Health, Safety, and Personal Rights risk to 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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
LIC809 (FAS) - (06/04)
Page: 4 of 7


Document Has Been Signed on 05/12/2022 05:20 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: DREAM HOME BOARD AND CARE
FACILITY NUMBER: 197608797

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/17/2022
Section Cited

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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: (6) To leave or depart the facility at any time and to not be locked in...
This requirement is not met as evidence by:
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Based on observation, the licensee did not comply with the section cited above in 2 out of 2 exit gates. This poses an immediate Health, Safety, and Personal Rights risk to residents in care.
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Type A
05/17/2022
Section Cited

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87465 Incidental Medical and Dental Care (h)(1) Medications shall be centrally stored... (C) Because of ...the habits of other persons in the facility, the medications are determined by either a physician, the administrator, or Department to be a safety hazard to others.
This requirement is not met as evidenced by:
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Based on observation and interview, the licensee did not comply with the section cited above in 5 out of 5 medications in Bedroom #5. This poses an immediate Health, Safety, and Personal Rights risk to 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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
LIC809 (FAS) - (06/04)
Page: 5 of 7


Document Has Been Signed on 05/12/2022 05:20 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: DREAM HOME BOARD AND CARE
FACILITY NUMBER: 197608797

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/10/2022
Section Cited

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87470 Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and... (1)(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.
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This requirement is not met as evidenced by:

Based on observation, the licensee did not comply with the section cited above in 2 out of 2 staff not wearing masks. This poses a potential Health, Safety, and Personal Rights risk to residents in care.
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Type B
06/10/2022
Section Cited

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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:
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Based on observation, the licensee did not comply with the above cited section through not providing a screening station for all visitors, residents, and staff. This poses a potential Health, Safety, and Personal Rights risk to 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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
LIC809 (FAS) - (06/04)
Page: 6 of 7


Document Has Been Signed on 05/12/2022 05:20 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: DREAM HOME BOARD AND CARE
FACILITY NUMBER: 197608797

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/10/2022
Section Cited

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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: (1) To be accorded dignity in their personal relationships with staff

This requirement is not met as evidenced by:
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Based on observation the licensee did not comply with the section cited above in 1 out of 1 residents requesting to go outside, which poses a potential Health, Safety, and Personal Rigths risk to 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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
LIC809 (FAS) - (06/04)
Page: 7 of 7