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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609342
Report Date: 03/11/2021
Date Signed: 03/12/2021 04:16:38 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: 162DATE:
03/11/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH: Licensee Nonna Shapiro and Administrator Lusine HakobyanTIME COMPLETED:
03:30 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 Lusine Hakobyan.

During the Technical Assistance (TA) Visit conducted on 3/10/21, Licensing was informed by Nonna that the facility had not been conducting surveillance testing between the dates of 2/10/21 to 3/10/21. According to Provider Information Notice (PIN) 20-38 released on 10/6/2020, Facilities should conduct surveillance testing of 25 percent of all staff every 7 days (e.g., choose different staff to test every 7 days). As a facility with an open covid-19 outbreak, mass testing was required weekly for staff and residents by the department of health as an additional guideline.

PIN 20-46, released on 12/23/2020, states that failure to comply with COVID-19 guidelines may be considered conduct inimical to the health or safety of persons in care. It may also be a violation of licensing requirements, including, but not limited to, a resident’s personal right to be accorded safe and healthful accommodations.

Deficiency cited and noted on 809D



Exit interview was conducted via telephone with Nonna Shapiro and copy of this report and 809D emailed for review and signature. Appeal rights discussed and will be provided in the email as well.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2021
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: 03/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/12/2021
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, furnishings and equipment.
This was not met as evidenced by:
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Facility did not conduct weekly surveillance testing from the date of 2/10/2021 to 3/11/2021. This poses a potential health and safety risk for the residents receiving care and supervision in the facility.
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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: 03/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2021
LIC809 (FAS) - (06/04)
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