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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609033
Report Date: 03/03/2022
Date Signed: 03/03/2022 04:51:09 PM


Document Has Been Signed on 03/03/2022 04:51 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:SANTA ANITA HOUSEFACILITY NUMBER:
197609033
ADMINISTRATOR:DEMIRJIAN, GARYFACILITY TYPE:
740
ADDRESS:211 WEST SANTA ANITA AVETELEPHONE:
(747) 283-1002
CITY:BURBANKSTATE: CAZIP CODE:
91502
CAPACITY:6CENSUS: 4DATE:
03/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:41 PM
MET WITH:Gary Demirjian, AdministratorTIME COMPLETED:
04:53 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required- 1-year visit focusing on COVID-19 Infection Control Practices. LPA was greeted by Arpenik Hovhannisyan Caregiver and Administrator Gary Demirjin arrived a short time later and LPA explained the purpose of the visit. Administrator certificate expires 04/02/22 Last fire drill was on 02/04/2022

Structure:
The Facility is a single story structure in a residential area with 4 resident bedrooms and day bed for staff, there’s 1 dining room, 2 full bathrooms, a kitchen. A laundry room, a family/TV room area. There is an area on the back premises with tables and chairs and shade. All the resident’s bedrooms are spacious and will easily accommodate the resident's furnishings. The passageway and walkways are free of hazard and free from obstruction. Facility has hospice waiver for 2 residents. Currently there is 0 hospice resident.

The following were observed/inspected:

· COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept.
· Water temperature measured between 105 – 120 degrees F which is within regulation range.
· Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote hand washing, cough/sneeze etiquette, and physical distancing.
· Facility has one designated isolation room.
· Four client rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· Four client rooms were not equipped with alcohol-based hand sanitizer but is available throughout the facility.
· Four (4) centrally stored client medication records were reviewed.
· Staff responsible for direct care and supervision were observed wearing masks.
· Clients were not observed wearing masks but adhering to public health social distance guidelines.
· Sufficient supply of perishable food for 2 days & non-perishable foods for 7 days were observed.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 03/03/2022 04:51 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: SANTA ANITA HOUSE
FACILITY NUMBER: 197609033

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the facility did comply in 3 out of 4 persons which poses an immediate health, safety or personal rights risk to persons in care. 3 of 4 residents medications records were incomplete.
POC Due Date: 03/14/2022
Plan of Correction
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Licensse will provide POC and email LPA proof.
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: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SANTA ANITA HOUSE
FACILITY NUMBER: 197609033
VISIT DATE: 03/03/2022
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· A posted Emergency Disaster Plan was observed posted at facility.
· PPE's were observed.
· Staff and resident files were not reviewed during today's visit.
· Deficiencies were observed during today’s visit. (please see 809D for details)

· Exit interview was conducted with Administrator Gary Demirjian . A copy of the report was provided.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022
LIC809 (FAS) - (06/04)
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