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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609342
Report Date: 02/02/2021
Date Signed: 02/03/2021 04:43:00 PM

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:LOS FELIZ GARDENSFACILITY NUMBER:
197609342
ADMINISTRATOR:SHAPIRO, NONNAFACILITY TYPE:
740
ADDRESS:205 E LOS FELIZ ROADTELEPHONE:
(818) 241-2273
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:199CENSUS: 165DATE:
02/02/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Licensee Nonna Shapiro and Administrator Lucine HakobyanTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jose Villalobos conducted a case management visit with the above facility. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted telephonically with Licensee Nonna Shapiro and Administrator Lucine Hakobyan.

During the Technical Assistance visit on 1/26/21, licensee and administrator failed to protect the personal rights of clients in care to receive safe and healthful accommodations and engaged in conduct inimical to the health, welfare, and safety of clients in care, in that facility staff Nonna Shapiro and Administrator Lucine Hakobyan failed to wear face coverings while working in the licensed facility, in violation of official government orders requiring the wearing of face coverings while working under specified conditions. This poses an immediate risk to resident in care as the facility is currently have an COVID 19 outbreak.

Per Title 22 California Regulation Code Chapter 8 Division 6; 87468.1 Personal Rights of Residents in All Facilities; (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

See LIC 809D for deficiencies.

Exit interview was conducted via telephone with Licensee Nonna Shapiro and Administrator Lucine Hakobyana. Appeal rights were discussed. A copy of this report, 809D, and appeal rights were emailed for review and signature.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2021
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LOS FELIZ GARDENS
FACILITY NUMBER: 197609342
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/08/2021
Section Cited

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87468.1 Personal Rights of Residents in All Facilities; (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations...
This was not met as evidenced by:
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LPA observed staff not wearing face masks while performing job tasks in the licensed facility which poses an immediate risk to residents in care as the facility currently has a COVID 19 outbreak.
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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: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2021
LIC809 (FAS) - (06/04)
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