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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608927
Report Date: 09/15/2022
Date Signed: 09/15/2022 12:30:32 PM


Document Has Been Signed on 09/15/2022 12:30 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. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:JUST LIKE HOME IIFACILITY NUMBER:
197608927
ADMINISTRATOR:MARAT DAVIDIANFACILITY TYPE:
740
ADDRESS:13524 CHANDLER BLVD.TELEPHONE:
(818) 769-9955
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91423
CAPACITY:6CENSUS: 6DATE:
09/15/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Marat Davidian TIME COMPLETED:
11:30 AM
NARRATIVE
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On 9/15/2022, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced Case Management Deficiencies visit due to deficiencies observed during the investigation of complaint control #29-NP-20211202105836. LPA Urena met with the administrator Marat Davidian and explained the reason for the visit.

During the investigation, the LPA learned while interviewing staff, that staff were providing care for R1’s pressure injury. R1’s pressure injury developed while in the care of the facility. On 11/017/2021, records review of Home Health Care Services revealed that HHCS staff reported that upon R1’s skin assessment, it was observed that there was an open wound on the sacral area with a diameter of 2cm. x 3cm. The physician ordered wound care for R1. HHCS staff provided the wound care per the physician’s orders, and instructed facility staff to observe the wound, and provide wound care regimen daily. The LPA was concerned what type of “wound care” the staff was providing, as only appropriately skilled professionals (Licensed Vocational Nurse [LVN] or higher) are allowed to provide wound care for pressure injuries.

On 08/29/2022, staff interviews revealed that staff kept the wound area clean, by irrigating the wound with a cleaning solution, applying ointments around the wound area, and covering the wound with a dry dressing. The administrator’s interview revealed that they were aware of the change in condition, and stated that staff was instructed to only change the dressing and apply moisture cream around the sacral wound. Only appropriately skilled professionals are allowed to care for pressure injuries.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Civil penalties assessed.

Citations were issued. Exit interview conducted with the administrator, and signatures were obtained. A copy of the report and Appeal Rights were issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022
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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Document Has Been Signed on 09/15/2022 12:30 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. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: JUST LIKE HOME II
FACILITY NUMBER: 197608927

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/30/2022
Section Cited

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87631 (a)(3)(A)(B) Healing wounds: Residents with a stage one or two pressure injury must have the condition
diagnosed by a physician… (A) The resident shall receive care for the pressure injury from a physician or an appropriately skilled professional; (B) All aspects of care by... facility staff shall be documented in the resident's file. This requirement is not met as evidenced by:
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Based on the interviews, staff provided care for pressure injuries, which can only be cared by a skilled professional, which poses an immediate health and safety 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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022
LIC809 (FAS) - (06/04)
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