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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197608972
Report Date:
06/16/2023
Date Signed:
06/16/2023 04:28:53 PM
Document Has Been Signed on
06/16/2023 04:28 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 NORTH
,
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:
06/16/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:05 AM
MET WITH:
Sofia Ghazaryan, Administrator
TIME COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analyst(LPA) Christine Yee conducted an unannounced required Annual Inspection using the CARE tool and met with Sofia Ghazaryan, Administrator. LPA Yee explained the reason for today's visit.
The facility is a single storey home consisting of a dining room, living room, kitchen, five(5) bedrooms of which one is designated for live-in staff, two common bathrooms and one staff bathroom. The previous attached garage was converted to living quarters with a separate address. Cameras are in use in the common areas. The facility is fire cleared for 4 ambulatory, 1 non-ambulatory and 1 bedridden residents.
Due to time constraints, only the following Annual Care Tool Domains were reviewed - Infection Control, Operational Requirements, Physical Plant and Environmental Safety, Staffing and Personnel Records-Training. Per review, of the noted domains the following were observed:
the Licensee does not have files containing the required documents for the Administrator and each employee
no evidence of a criminal record clearance and association for the Susan Roberts, back up administrator
Continued on LIC9099-C
SUPERVISOR'S NAME:
Jeralyn Ann Pfannenstiel
TELEPHONE:
(818) 596-4343
LICENSING EVALUATOR NAME:
Christine Yee
TELEPHONE:
(747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE:
06/16/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
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Document Has Been Signed on
06/16/2023 04:28 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 NORTH
,
21731 VENTURA BLVD. #250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
ANTHEM SENIOR CARE
FACILITY NUMBER:
197608972
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/16/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above in 3 out of 3 records requested, per Licensee, the Physician's report are somewhere and could not be provided to LPA for review and which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
07/07/2023
Plan of Correction
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Licensee will ensure that all employees are in good health and physically and mentally capable of performing assigned task. Good physical health shall be verified by a health screening, including a chest x-ray or intradermal test performed by a physician not more than 6 months prior to seven days after employment or licensure. The Licensee will provide evidence that the health screening with the results of a TB test was completed by 7/7/23
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:
Christine Yee
TELEPHONE:
(747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE:
06/16/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/16/2023
LIC809
(FAS) - (06/04)
Page:
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of
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Document Has Been Signed on
06/16/2023 04:28 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 NORTH
,
21731 VENTURA BLVD. #250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
ANTHEM SENIOR CARE
FACILITY NUMBER:
197608972
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/16/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above in 1 out of 3 records reviewed, which poses an immediate health, safety or personal rights risk to persons in care. Susan Roberts, Backup Administrator was present at the facility on today's visit and was not able to provide evidence that a criminal record clearance was obtained and was not associated to the facility as of today's visit. Immediate civil penalties were assessed.
POC Due Date:
06/17/2023
Plan of Correction
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The Licensee will provide a written plan as to how the Licensee will ensure that all employees and individuals who require a criminal record clearance obtain one and are associated to the facility prior to being present at the facility by 6/17/23. Licensee will also notify Licensing once the clearance for is completed. IMMEDIATE CIVIL PENALTIES ASSESSED
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Pfannenstiel
TELEPHONE:
(818) 596-4343
LICENSING EVALUATOR NAME:
Christine Yee
TELEPHONE:
(747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE:
06/16/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/16/2023
LIC809
(FAS) - (06/04)
Page:
3
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Document Has Been Signed on
06/16/2023 04:28 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 NORTH
,
21731 VENTURA BLVD. #250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
ANTHEM SENIOR CARE
FACILITY NUMBER:
197608972
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/16/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in 1 out of 2 bathrooms inspected, the common bathroom in the back did not have a non-skid mat, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/23/2023
Plan of Correction
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Licensee will purchase a non-skid mat for the common bathroom located in the back of facility. Licensee will provide evidence that a non-skid mat was purchased and placed in the bathroom.
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 3 files requested for review and was informed that the facility does not have files for the 3 staff, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/07/2023
Plan of Correction
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Per discussion with the Licensee/Administrator, due to the Backup Administrator being out of town, addtional time is needed to create files containing the required document for each employee, including the Administrator
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:
Christine Yee
TELEPHONE:
(747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE:
06/16/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/16/2023
LIC809
(FAS) - (06/04)
Page:
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Document Has Been Signed on
06/16/2023 04:28 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 NORTH
,
21731 VENTURA BLVD. #250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
ANTHEM SENIOR CARE
FACILITY NUMBER:
197608972
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/16/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(6)
Personnel Requirements - General
(6) The licensee shall maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2). For on-the-job training, documentation shall consist of a statement or notation, made by the trainer, of the content covered in the training. Each item of documentation shall include a notation that indicates which of the criteria of Section 87411(c)(3) is met by the trainer.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 3 files requested for review/evidence of staff training and was advised that training logs are not kept by the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/07/2023
Plan of Correction
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Licensee will submit a written plan indicating how the facility will ensure that all staff training are recorded and contains the following information - date of training, subject of the training, material covered, hours of training provided and the name of the trainer. Provide LPA with the written plan by 7/7/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Pfannenstiel
TELEPHONE:
(818) 596-4343
LICENSING EVALUATOR NAME:
Christine Yee
TELEPHONE:
(747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE:
06/16/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/16/2023
LIC809
(FAS) - (06/04)
Page:
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of
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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
WOODLAND HILLS NORTH
,
21731 VENTURA BLVD. #250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
ANTHEM SENIOR CARE
FACILITY NUMBER:
197608972
VISIT DATE:
06/16/2023
NARRATIVE
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the common bathroom in the back does not have a non-skid mat
the bedrooms do not have lamps but sufficient lighting was observed.
current CPR/first aid cards were observed
Deficiencies are being cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Immediate CIVIL PENALTIES were assessed.
Any deficiencies not cited on today's visit will be addressed on a return visit.
Exit interview was conducted, Appeals Rights discussed and a copy was provided.
SUPERVISOR'S NAME:
Jeralyn Ann Pfannenstiel
TELEPHONE:
(818) 596-4343
LICENSING EVALUATOR NAME:
Christine Yee
TELEPHONE:
(747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE:
06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/16/2023
LIC809
(FAS) - (06/04)
Page:
6
of
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