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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608972
Report Date: 06/18/2021
Date Signed: 06/18/2021 11:38:51 AM

COMPREHENSIVE INSPECTION
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 CAREFACILITY NUMBER:
197608972
ADMINISTRATOR:GHAZARYAN, SOFIAFACILITY TYPE:
740
ADDRESS:12813 FRIAR STREETTELEPHONE:
(818) 445-0993
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY:6CENSUS: 5DATE:
06/18/2021
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Sofia Ghazaryan, AdministratorTIME COMPLETED:
11:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Salia Walker and Brian Balisi conducted an unannounced Case Management - Annual Continuation visit to address deficiencies which were observed during the annual visit which was conducted on June 14, 2021, though were not cited. LPAs met with administrator Sofia Ghazaryan at 08:30AM and explained the reason for the visit.

During the physical plant tour on June 14, 2021 between 9:12 a.m. and 12:30 p.m., LPAs Salia Walker and Aja Richardson observed cameras set up in two (2) resident bedrooms. The LPAs also observed that the Activity room was converted into a resident bedroom, without the proper city permit through building and safety, an approved fire clearance or an approval from Community Care Licensing. In addition, upon review of the facility file, the facility sketch had not been updated to reflect changes, nor was a LIC 200 and the required $25 fee submitted to request the capacity increase. There were no residents residing in the room during this visit. The bed shall be removed until the proper clearances have been obtained.

LPAs had verbally informed the administrator to remove the cameras and it was noted on the LIC 809, the administrator had yet to remove the cameras. During today’s visit , LPAs did observe camera still installed in bedrooms. Administrator informed LPAs, she received confirmation this morning that the contractor is scheduled to visit the facility on Monday the June 21, 2021 to remove all cameras that are installed in residents’ bedrooms. LPAs observed Administrator contact the contractor via phone and confirm the appointment for Monday the 21st.

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 PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/21/2021
Section Cited

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Additional Personal Rights of Residents in Privately Operated Facilities. (a) residents in privately operated residential care facilities for the elderly shall have the following personal rights: To have a reasonable level of personal privacy in accommodations.. visits, communications, telephone conversations
This requirement is not met as evidenced by:
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During the inspection LPAs observed cameras installed in (2) resident bedrooms. This poses as an immidiate health, safety and personal rights risk to residents in care.
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meeting log that section 87468.2 was reviewed with all employees. Administrator will provide log to LPA via email by end of day 6/21/2021

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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: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2021
LIC809 (FAS) - (06/04)
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