197608972-6-14-2021-29-AS-SWAR-C3YQM7-20210614121703

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608972
Report Date: 06/14/2021
Date Signed: 06/14/2021 12:18:13 PM

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:	ANTHEM SENIOR CARE		FACILITY NUMBER:	197608972
ADMINISTRATOR:	GHAZARYAN, SOFIA		FACILITY TYPE:	740
ADDRESS:	12813 FRIAR STREET		TELEPHONE:	(818) 445-0993
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY:	6	CENSUS: 5	DATE:	06/14/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:12 AM
MET WITH:	Sofia Ghazaryan, Administrator		TIME COMPLETED:	12:30 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Salia Walker and Aja Richardson arrived at the facility unannounced to conduct a required annual visit at 09:12AM. This annual had a specific emphasis on infection control practices and procedures. The LPAs met with Administrator Sofia Ghazaryan and explained the reason for the visit.

The LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards.

BEDROOMS: The LPAs observed the resident bedrooms which were furnished with clean linens, appropriate furnishings and sufficient lighting. At 09:24AM LPAs observed cameras in each of the resident’s rooms. Administrator was advised that cameras need to be removed as this is a violation of resident’s personal rights.
RESTROOMS: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPAs advised the Administrator to ensure that bathrooms were stocked with paper towels and hand-washing signs. Restroom one (1) hot water measured at 113.1 Fahrenheit at 09:20AM. Restroom two (2) hot water measured at 110.1 Fahrenheit at 09:33AM.
KITCHEN: Knives are stored and locked in kitchen cabinet. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Hot water measured at 113.8 Fahrenheit at 09:44AM.
COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the hallway.
At 9:35AM, the laundry area was unlocked, and there were accessible laundry supplies and chemical. The Administrator secured it at the time of observation.

Continued on 809C...

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

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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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: ANTHEM SENIOR CARE	FACILITY NUMBER: 197608972
	VISIT DATE: 06/14/2021

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INFECTION CONTROL: During today’s visit, the LPAs spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. LPAs observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient and facility has sufficient disinfectants. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time and the LPA reviewed facility’s policies and procedures as it pertains to infection control.

At 09:41AM LPAs observed accessible medications in unlocked hallway closet. Administrator secured all medications at the time of observation.
The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. The garage contains additional nonperishable and perishable food items. The garage is detached to the facility.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: ANTHEM SENIOR CARE	FACILITY NUMBER: 197608972
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, LPAs observed the licensee did not comply with the section cited above in (5) out of (5) persons which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/14/2021
	Plan of Correction
1 2 3 4	Plan of correction cleared on today's visit as medication was secured by administrator.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: ANTHEM SENIOR CARE	FACILITY NUMBER: 197608972
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87211(a)

Reporting Requirements

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 1 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/17/2021
	Plan of Correction
1 2 3 4	Plan of action will be cleared upon submittion of mitigiation plan by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

LIC809 (FAS) - (06/04)

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