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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609542
Report Date: 10/13/2021
Date Signed: 10/13/2021 05:11:58 PM

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:BLYTHE STREET ELDERLY CAREFACILITY NUMBER:
197609542
ADMINISTRATOR:OHANYAN, NONAFACILITY TYPE:
740
ADDRESS:13367 BLYTHE STREETTELEPHONE:
(323) 947-7005
CITY:N HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:5CENSUS: 2DATE:
10/13/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Nona Ohanyan, AdministratorTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Salia Walker conducted an unannounced Case Management-Deficiencies inspection visit at the facility today due to deficiencies observed during the initial inspection visit of complaint control # 29-AS-20211012112342.

At 8:51 a.m., the LPA observed that the gate entrance was not single latched, and was secured with a deadbolt mechanism. Staff #1 (S1) had to unlock the gate from the inside to allow the LPA on to the property. At 9:06 a.m., the LPA informed the administrator this is a fire safety and fire clearance violation. The administrator stated that the mechanism of the lock will be changed to ensure that it was single latch only. At 4:19 p.m., the LPA observed a new single-latch lock on the gate entrance.


At 8:55 a.m., the LPA was not screened, and temperature was not checked prior to entering the facility. At 9:25 a.m., the LPA inquired with the administrator regarding the facility’s protocol around visitation, specifically the visitation protocol from November 2020 until present time. The administrator stated that the facility does not have a central entry point for temperature checks, signing ins, and symptom screening. The administrator also stated that she ‘didn’t know we were still doing that.’ The LPA advised the administrator that CDSS records reflect the facility’s Mitigation Plan Report indicating the requirement of a central entry point for temperature checks, signing ins, and symptom screening was submitted to CDSS. The administrator acknowledged that the Mitigation plan was signed and submitted to CCLD. The LPA advised the administrator this is a citation under regulation 87468.1(a)(2)., and the facility must comply with the directives given by the Department and the California Department of Public Health as it relates to visitation during COVID-19. The facility’s policies and procedures as it pertains to infection control are inadequate.
Recommendations included: Identify a central entry point for symptom screening; temperature checks, and sanitation station for visitors; Continue to check and document temperatures of staff and residents daily. Continue daily symptom screening; Posting Provider Information Notices (PINs) and educating staff, residents, and families on changing policies and procedures from the Department.
Continue on LIC 809C..
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
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 6
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: BLYTHE STREET ELDERLY CARE
FACILITY NUMBER: 197609542
VISIT DATE: 10/13/2021
NARRATIVE
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At 9:02 a.m., the LPA observed the medication file cabinet to be open and accessible. The LPA informed the S1, and the administrator confirmed that they would repair the mechanism to ensure that medications remain locked and inaccessible.

From 9:08 a.m. until 11:20 a.m., the LPA reviewed resident files with the administrator Nona Ohanyan. Resident files were reviewed for admission agreements, medical assessments, appraisals, consent forms and medication records. Upon review of resident files with the administrator, it was observed that six (6) out of six (6) resident files provided to the LPA did not contain required documentation such as; full admission agreements, centrally stored medication logs, complete medical assessments, appraisals, and consent forms. One (1) out of six (6) resident files did not have the full Hospice care plans. The administrator stated that Hospice agency only provided the care plan summary, and not the full report.

From 11:20 a.m. until 12:05 p.m., the LPA reviewed staff files with administrator Nona Ohanyan. Record review revealed that two (2) out of three (3) staff are not associated and background cleared with DOJ under this facility. The administrator stated she previously attempted to associate both staff to the facility back in 2018. The LPA requested the documentation submitted to CCLD, as they were not in the staff files. The administrator could not provide the documentation requested by the LPA. During today's visit, the administrator submitted the appropriate documentation to complete the clearance transfers.

Pursuant to Title 22 of the California Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Civil penalties issued.

Exit interview conducted. A copy of today's report and appeal rights were provided.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
LIC809 (FAS) - (06/04)
Page: 2 of 6
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: BLYTHE STREET ELDERLY CARE
FACILITY NUMBER: 197609542
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/13/2021
Section Cited

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87465(h)(2) Incidental Medical and Dental Care. The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees...
This requirement is not met as evidenced by:
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Based on observation, the licensee did not comply with the section cited above, as the medications were accessible during today’s visit, which poses an immediate health and safety risk to residents in care.
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Type B
10/13/2021
Section Cited

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87468(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 requirement is not met as evidenced by:
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Based on observation, the licensee did not comply with the section cited above, as the LPA could not identify a central entry point for temperature check, signing in, and symptom screening, which poses a potential personal rights risk to persons 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 PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2021
LIC809 (FAS) - (06/04)
Page: 3 of 6
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: BLYTHE STREET ELDERLY CARE
FACILITY NUMBER: 197609542
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/13/2021
Section Cited

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87203 Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
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Based on observation, the licensee did not comply with the section cited above, as the entrance gate was locked from the inside of the property to the facility grounds with the means of a deadbolt mechanism, which poses an immediate health and safety risk to residents in care.
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Type A
10/13/2021
Section Cited

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87355(e)(2) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... in a licensed facility: (2) Request a transfer of a criminal record clearance

This requirement is not met as evidenced by:
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Based on record review, the licensee did not comply with the section cited above, as two individuals (S1, S2) have been working at the facility without a criminal record transfer, which poses an immediate 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 PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2021
LIC809 (FAS) - (06/04)
Page: 4 of 6
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: BLYTHE STREET ELDERLY CARE
FACILITY NUMBER: 197609542
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/13/2021
Section Cited

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87633(b) Hospice Care of Terminally Ill Residents: (b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:
This requirement is not met as evidenced by:
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Based on record review, the licensee did not comply with the section cited above, as one (1) out of six (6) resident files did not contain the resident's full Hospice care plan, which poses a potential health, and safety risk to persons 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 PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2021
LIC809 (FAS) - (06/04)
Page: 5 of 6
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: BLYTHE STREET ELDERLY CARE
FACILITY NUMBER: 197609542
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/13/2021
Section Cited

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87506 Resident Records: (d)All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours..

This requirement is not met as evidenced by:
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Based on record review, the licensee did not comply with the section cited above, as six (6) out of six (6) resident files did not contain required documents, which poses a potential health, and safety risk to persons in care.
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Type B
10/13/2021
Section Cited

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87465 Incidental Medical and Dental Care:(h)The following requirements shall apply to medications which are centrally stored:(6)The licensee shall be responsible for assuring that a record of centrally stored prescription medications..is maintained..
This requirement is not met as evidenced by:
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Based on record review, the licensee did not comply with the section cited above, as six (6) out of six (6) resident files did not contain centrally stored medication logs, which poses a potential health, and safety risk to persons 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 PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2021
LIC809 (FAS) - (06/04)
Page: 6 of 6