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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608954
Report Date: 08/06/2024
Date Signed: 08/06/2024 02:50:03 PM


Document Has Been Signed on 08/06/2024 02:50 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:LIEBELOVE CARE INCFACILITY NUMBER:
197608954
ADMINISTRATOR:GALINA MELKONYANFACILITY TYPE:
740
ADDRESS:6500 QUARTZ AVENUETELEPHONE:
(747) 888-9984
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: DATE:
08/06/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Galina MelkonyanTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Angela Barutyan and Trevor Byrne arrived at the facility unannounced to conduct a Case Management - Legal/Non-compliance visit at 12:50PM. The purpose of today’s visit was to ensure the facility was maintaining substantial compliance as discussed in the Non-Compliance Conference that took place on 08/24/2022. As a result of the non-compliance conference, the licensee is placed on frequent monitoring for a period of two years. The LPAs met with Licensee/Administrator Galina Melkonyan and explained the reason for the visit.


During today’s visit, LPAs conducted a plant tour at 12:52PM of the facility which includes six (6) resident bedrooms, one (1) staff room, four (4) bathrooms, kitchen, and common areas to ensure there are no health and safety hazards. At 01:07PM, LPAs observed 7 (seven) expired food items in the kitchen. Staff disposed of all expired items immediately.

At 01:20PM, LPAs began a medication review for 5 (five) out of 5 (five) residents. All medication records were in order. At 01:33PM, LPAs observed 1 (one) medication for Resident #1 (R1) not in its original packaging. The medication label is attached to the box, but the box was discarded and the facility did not have the label. LPAs explained to Licensee that all medications need to be stored in original packaging with the medication label affixed.

During today’s visit, LPAs interviewed 2 (two) residents and 1 (one) staff.

Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Administrator was informed that failure to correct deficiencies may result in civil penalties. Exit interview conducted, report issued, and appeal rights provided.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angela BarutyanTELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024
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 08/06/2024 02:50 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: LIEBELOVE CARE INC
FACILITY NUMBER: 197608954

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/13/2024
Section Cited
CCR
87465(h)(4)

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(h) The following requirements shall apply to medications which are centrally stored:
(4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.
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Administrator will submit a statement of understanding of the section cited above and submit to CCL by 08/13/2024. Administrator has a refill of the medication with the label and will follow the instructions on the label.
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Based on medication review, 1 (one) medication for a resident was not stored in its original packaging with the label, which poses a potential health and safety risk to residents in care.
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Type B
08/07/2024
Section Cited
CCR87555(b)8

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(b) The following food service requirements shall apply:
(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.
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Administrator discarded all food items immediately. POC is cleared.
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Based on observation, 7 (seven) food items were expired which poses a potential 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angela BarutyanTELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2