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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608972
Report Date: 08/08/2024
Date Signed: 08/08/2024 06:33:40 PM


Document Has Been Signed on 08/08/2024 06:33 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: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:
08/08/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:17 PM
MET WITH:Sofiya Ghazaryan, AdministratorTIME COMPLETED:
06:40 PM
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Licensing Program Analyst(LPA) Christine Yee conducted an unannounced case management visit due to the deficiencies observed during a visit to the facility today. LPA Yee met with Sofia Ghazaryan, Administrator. The reason for today's visit was explained.

On today's visit, it was observed during file review that Resident #1, Resident #4 and Resident #5 are on hospice and the Department was not notified of the initiation of hospice services.
Per tour of the facility, the front door was observed with an operational auditory device and the back outside exiting doors located in bedroom #4 and the glass sliding door did not have any auditory devices and bedroom #3 had a auditory device that was not operational.
Resident #1, who is on hospice, does not have a care plan in place and there is no written evidence that staff have received the appropriate training for the care of the resident.
Resident #2's hospital bed is not functioning and the needs to be replaced.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8

Exit interview was conducted, APPEALS RIGHTS discussed and a copy was given.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024
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 08/08/2024 06:33 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: ANTHEM SENIOR CARE
FACILITY NUMBER: 197608972

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/15/2024
Section Cited
CCR
87705(j)

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Care of Persons with Dementia: (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
This requirement was not met as evidenced per tour of the facilit, it was observed that bedroom #4 an back sliding glass door did
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Licensee will ensure that all outside exiting doors have auditory devices that will monitor and alert staff when a resident leaves the facility by 8/15/24
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not have an auditory device installed on the door and the auditory device on bedroom #3 had a auditory device that was no operational
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Type B
08/15/2024
Section Cited
CCR87633(a)(4)

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Hospice Care of Terminally Ill Residents: The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill...and receive hospice services from a hospice agency in the facility when all of the following conditions are met: A written hospice care plan specifies the care, services
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Licensee will review Title 22, Sections 87632 and 87633 and provide a signed written statement that the sections were read and understood and will be adhered to. Licensee will also contact the Hospice agency for Resident #1 and any other resident's hospice agency to obtain any and all necessary
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and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each resident...prior to the initiation of hospice services in the facility for that resident, Resident #1 does not have a care plan
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documentation needed and maintain in the residents' files. Provide evidence by 8/15/24 that the files have been updated and contain all the required documentation.
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: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/08/2024 06:33 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: ANTHEM SENIOR CARE
FACILITY NUMBER: 197608972

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/15/2024
Section Cited
CCR
87303(a)

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Maintenance and Operation:The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:
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Licensee will have the hospital bed repaired or replaced to allow the resident easy access into bed and a mattress in good condition is provided and the full bed rail is removed. Provide evidence that all the above corrections have been made by 8/15/24
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Resident #2's hospital bed was observed to be non-operational and could not to be lowered or raised to allow easy access into bed and replace the mattress as needed since it was observed propped by bedding below the mattress and the full rail needs to be removed.
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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: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 08/08/2024 06:33 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: ANTHEM SENIOR CARE
FACILITY NUMBER: 197608972

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/15/2024
Section Cited
CCR
87632(d)(2)

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Hospice Care Waiver: If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver as necessary to ensure the well-being of terminally ill residents and of all other facility residents, which shall include, but not be limited to, the following
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Licensee will review Title 22, Section 87632 and 1. submit a statement that the section was read and understood and will be adhered to 2. Licensee will submit hospice initiation letters for Resident #1, Resident #4 and Resident #5 by 8/15/24
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requirements: The licensee shall notify the Department in writing within five working days of the initiation of hospice care.....The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice. Dept not notified of R1, R4 & R's hospice initiation
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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: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4