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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608972
Report Date: 10/12/2021
Date Signed: 10/12/2021 06:41:46 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 CAREFACILITY NUMBER:
197608972
ADMINISTRATOR:GHAZARYAN, SOFIAFACILITY TYPE:
740
ADDRESS:12813 FRIAR STREETTELEPHONE:
(818) 445-0993
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY:6CENSUS: 6DATE:
10/12/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Sofia Ghazaryan, AdministratorTIME COMPLETED:
06:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Salia Walker conducted an unannounced Case Management- Deficiencies inspection visit at the facility today due to deficiencies observed during the initial 10-day complaint inspection of complaint control # 29-AS-20211004144804.

At 10:07 a.m., the LPA observed accessible medications in unlocked hallway closet. Administrator secured all medications at the time of observation. On 06/14/2021, the Licensee was cited for the same violation during a required annual visit. Therefore, this is a repeat violation and civil penalties will be assessed. At 4:53 p.m., the LPA observed five (5) out of six (6) resident medications in kitchen cabinet were prepared for more than 24 Hours. The LPA advised the Administrator that per Title 22 Regulation each resident's medication shall be stored in its originally received container, and no medications shall be transferred between containers. From 4:53 p.m. until 6:15 p.m., the LPA conducted a Medication assessment with the administrator Sofia Ghazaryan. All medication was placed back into its original containers.



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

Repeat Violation assessed, Immediate Civil penalties issued for $250.

Exit interview conducted, today's reports and appeal rights were reviewed and issued.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
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: 10/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/12/2021
Section Cited

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87465 Incidental Medical and Dental Care:(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..
This requirement is not met as evidenced by:
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Based on LPA's observation, the licensee did not comply with the section cited above, as medications were in a unlocked hallway closet accessible to residents in care, which poses an immediate health and safety risk to persons in care.
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Type A
10/12/2021
Section Cited

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87465 Incidental Medical and Dental Care:(h)The following requirements shall apply to medications which are centrally stored: (5)Each resident's medication shall be stored in its originally received container..
This requirement is not met as evidenced by:
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Based on LPA's observation and medication assessment, the lincensee did not comply with the section cited above, as five (5) out of six (6) resident medications were removed from its original container and prepared for more than 24-Hours, which poses an immediate health and safety risk to persons 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: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2021
LIC809 (FAS) - (06/04)
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