197609057-3-3-2025-31-AS-PKHN-DEEU9B-20250303142251

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609057
Report Date: 03/03/2025
Date Signed: 03/03/2025 02:25:18 PM

Document Has Been Signed on 03/03/2025 02:25 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	PRIMROSE 2		FACILITY NUMBER:	197609057
ADMINISTRATOR/ DIRECTOR:	NAIMUDDIN, MUBEEN		FACILITY TYPE:	740
ADDRESS:	8115 DE SOTO AVE		TELEPHONE:	(323) 387-2755
CITY:	CANOGA PARK	STATE: CA	ZIP CODE:	91304
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	03/03/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:35 AM
MET WITH:	Mubeen Naimuddin-Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:00 PM

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On 3/3/2025 at 9:30am Licensing Program Analyst (LPA) Perchui Milena Khurshudyan arrived at this facility to conduct a required Annual Inspection. Upon arrival LPA was greeted by the Caregiver John Enriquez who granted access to the facility. LPA introduced herself by showing her badge and explained the reason for the visit. LPA Khurshudyan reviewed the required postings on a wall next to the entrance area. The Administrator arrived shortly after.
The inspection tool was used to complete the visit.
At 10:25am. LPA with the help of the caregiver began a physical plant tour of the facility and the following was observed: This is a single-story building with seven (7) bedrooms, of which 6 bedrooms are designated for residents’ private use and one bedroom designated for staff use only. There are five (5) bathrooms, kitchen, common areas: living and dining rooms, and outdoor areas. It has an approved fire clearance for six (6) Non-ambulatory residents, of which six (6) may be Bedridden. Facility also has Hospice waiver for six (6) residents.

Common Areas: The facility maintains a comfortable temperature at 70°F. The living room and dining area appeared generally clean and were properly furnished. No obstructions and or tripping hazards throughout the facility was observed.

Kitchen: At approximately 10:40am LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. LPA observed that cabinets containing chemicals were not locked and accessible to residents, sharps/knives and centrally stored medications were properly stored and locked inside the kitchen cabinet. There is a fire extinguisher on the kitchen wall which was last serviced on 08/12/2024.

Bedrooms: There are seven (7) bedrooms designated for residents use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Auditory alarms were tested and observed to be operational. Facility has awake staff.

Continue on LIC809-C

Nichelle Gillyard	TELEPHONE: (818) 596-4370
Perchui Khurshudyan	TELEPHONE: (818) 439-7073
	DATE: 03/03/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2025

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PRIMROSE 2	FACILITY NUMBER: 197609057
	VISIT DATE: 03/03/2025

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Bathrooms: At 10:50am LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured at 115.8°F. LPA observed appropriate grab bar and non-skid mats. All trash cans in bathrooms had fitted lids to protect from cross contamination.

Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 11:05am they were tested and observed to be operational.

Outside areas: At approximately, 11:20am LPA toured the outside area of the facility and observed appropriate outdoor furniture, with a covered shaded area for residents LPA discussed the importance of maintaining the care and supervision to meet the needs of residents. There are no bodies of water.

Laundry Room: Laundry machines are in a separate locked area outside of the facility. Disinfectants, laundry detergents and hygiene supplies were stored and inaccessible to residents in care.

Garage: The garage is currently being used as an office space and storage.

Between 11:45am to 12:40pm, LPA reviewed records of six (6) residents and four (4) staff members. Resident and staff records appeared to be complete and updated.

MEDICATION: LPA observed centrally stored medication and First Aid kit locked in the kitchen cabinet and inaccessible to residents in care. LPA observed First-aid kit is complete and has new manual. Facility has Dementia Care Program. PRN medications have written orders from a physician. The facility serves residents with dementia and facility has trained staff to meet the needs of residents who are diagnosed with dementia. Facility has two (2) staff for AM shift and two (2) awake caregiver for PM shift.

Administrative: Annual fee is current. All required signs are posted. LPA collected LIC500, LIC9020 and Certificate of Liability Insurance. The Administrator Certificate got renewed however still pending.

One citation issued during this visit, please see LIC809-D.

Exit interview conducted. Copy of report signed and delivered to the Licensee/Administrator.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui Khurshudyan	TELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2025

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 03/03/2025 02:25 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PRIMROSE 2	FACILITY NUMBER: 197609057
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87309(a)

Storage Space (a) Disinfectants, cleaning solutions…and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, Licensee did not ensure that all toxins are properly stored and inaccessible to residents, this poses an immediate health and safety risks to the residents in care.
	POC Due Date: 03/03/2025
	Plan of Correction
1 2 3 4	The staff immediately removed the toxins and kept in a locked cabinet. LPA also did not observe any other toxins around the house. Cleared during visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Nichelle Gillyard	TELEPHONE: (818) 596-4370
Perchui Khurshudyan	TELEPHONE: (818) 439-7073
	DATE: 03/03/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2025

LIC809 (FAS) - (06/04)

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