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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609356
Report Date: 01/11/2022
Date Signed: 01/11/2022 03:58:30 PM

Document Has Been Signed on 01/11/2022 03:58 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:YMZ ASSISTED LIVINGFACILITY NUMBER:
197609356
ADMINISTRATOR:REBEKA DURGARYANFACILITY TYPE:
740
ADDRESS:6206 KLUMP AVENUETELEPHONE:
(818) 322-8838
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 6CENSUS: 6DATE:
01/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Rebeka Durgaryan, AdministratorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Salia Walker arrived at the facility unannounced to conduct a required Annual visit. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Staff #1 (S1) at 1:08 p.m., and explained the reason for the visit.
The LPA toured the physical plant areas inside and outside at 1:16 p.m., to ensure there are no health and safety hazards.
BEDROOMS: The LPA observed the resident bedrooms which were furnished with clean linens, appropriate furnishings, and sufficient lighting
RESTROOMS: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap, paper products, and hand-washing signs in each restroom. From 1:17 p.m. until 1:19 p.m., the hot water temperatures measured between 142.5 and 147.4 degrees Fahrenheit in room #2’s private bathroom, and the common bathroom.
KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All cleaning supplies were observed to be properly stored and locked at time of visit. At 1:23 p.m., the LPA observed culinary knives accessible and unlocked in the drawer on the left side of the stove. S1 locked and secured all knives in the drawer, with a lock mechanism, on the right side of the stove during the visit. At 1:26 p.m., hot water measured at 163.2 degrees Fahrenheit from the facility kitchen faucet. At 1:34 p.m., the LPA observed accessible medications in the facility kitchen refrigerator. The LPA advised S1 all medication that requires refrigeration is to be stored in a locked container/ box. At 1:35 p.m., the LPA called the Administrator Rebeka Durgaryan to advise of the deficiencies observed during today’s visit. The administrator acknowledged understanding and stated S1 would secure the medication in a lock box currently stored in the facility garage. The administrator also stated she would send an individual to adjust the hot water temperate to the correct setting of between 105 and 120 degrees Fahrenheit.
Continue on LIC809C..
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2022
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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: YMZ ASSISTED LIVING
FACILITY NUMBER: 197609356
VISIT DATE: 01/11/2022
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COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed required postings in living room above the facility’s central entry point for symptom screening. One fire extinguisher was observed to be fully charged.
BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. One (1) in-ground pool was observed locked and secured during today’s visit. The garage is detached from the facility, and is currently being used as storage.
INFECTION CONTROL: During today’s visit, the LPA spoke with the administrator via telephone regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

The following deficiencies were observed (See LIC 809-D), and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties.

Today’s exit interview was conducted telephonically, with administrator Rebeka Durgaryan at 3:35 p.m., due to the administrator not being able to meet in person with the LPA pertaining to personal reasons. A copy of the report and appeal rights were provided via email.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/11/2022 03:58 PM - It Cannot Be Edited


Created By: Salia Walker On 01/11/2022 at 03:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: YMZ ASSISTED LIVING
FACILITY NUMBER: 197609356

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/12/2022
Section Cited

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87705(f)(1) Care of Persons with Dementia: (f)The following shall be stored inaccessible to residents with dementia: (1)Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement is not met as evidenced by:
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Based on LPAs observation, the licensee did not comply with the section cited above, as culinary knives were accessible during physical plant tour to residents with Dementia, which poses an immediate health and safety risk to residents in care.
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Type A
01/12/2022
Section Cited

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87705(f)(2) Care of Persons with Dementia. The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as... cleaning supplies ...
This requirement is not met as evidenced by:
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Based on LPAs observation, the licensee did not comply with the section cited above, as medications were accessible to residents with dementia in the facility kitchen refrigerator, which poses an immediate health and safety risk to residents in care.
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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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Salia Walker
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 01/11/2022 03:58 PM - It Cannot Be Edited


Created By: Salia Walker On 01/11/2022 at 03:11 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: YMZ ASSISTED LIVING
FACILITY NUMBER: 197609356

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/17/2022
Section Cited

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Maintenance and Operation(e)Water supplies.. shall be maintained as follows:(2)Faucets used by residents.. shall deliver hot water.. temperature controls.. to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
This requirement is not met as evidenced by:
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Based on LPAs observation, the licensee failed to ensure hot water temperature measured within 105 to 120 degrees Fahrenheit in private restroom, common restroom, and facility kitchen faucets, which poses an immediate health, and safety risk to residents in care.
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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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Salia Walker
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2022


LIC809 (FAS) - (06/04)
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