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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608927
Report Date: 03/02/2023
Date Signed: 03/02/2023 02:42:31 PM


Document Has Been Signed on 03/02/2023 02:42 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:
03/02/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Marat TIME COMPLETED:
02:42 PM
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An Informal Conference was conducted today in the Woodland Hills North Adult and Senior Care Regional Office. The purpose of this Informal Conference is to discuss deficiencies cited in complaint control #29-NP-20211202105836.

Present at today's meeting included licensee representatives Alexandra Vartapetova, and Administrator Marat Davidian, Licensing Program Manager (LPM) Jeralyn Pfannenstiel, and Licensing Program Analyst (LPA) Sandra Urena.



The informal conference process was explained to the Administrator. The Administrator was also informed that this Informal Conference is a part of the administrative action process and that further citations may result in a Non-Compliance Conference, which could lead to a referral for Administrative Review by the Department.

Brief History: The facility was first licensed in 12/14/2015, for a capacity of six residents.

LPM Pfannenstiel discussed deficiencies that were cited during the past three years. This included the complaint investigation, with allegations of failure to notice a resident’s change in condition, and retaining resident in the facility with a prohibited health condition, stage 4 pressure injury. In addition, the facility staff was providing wound care and were not appropriately skilled professionals, where deficiencies were issued on 09/15/2022 on a case management visit.

At this time, the licensee has cleared the Plan of Corrections in a timely manner. All parties discussed the complaint investigation and potential ramifications of the complaint findings.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2023
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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