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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609542
Report Date: 12/28/2022
Date Signed: 12/29/2022 08:01:32 AM


Document Has Been Signed on 12/29/2022 08:01 AM - 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: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: 3DATE:
12/28/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Nona TIME COMPLETED:
02:45 PM
NARRATIVE
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On 12/28/2022, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced Case Management Deficiencies visit at the facility due to deficiencies observed during the course of the investigations for C#29-AS-20220826155207. The LPA met with Licensee Nona Ohanyan and explained the reason for the visit.

During the course of the investigation for complaint C#29-AS-20220826155207, the LPA reviewed residents’ records. During the record review, the LPA found that the Licensee failed to ensure that a complete, and current record was maintained for R1. Additionally, the licensee failed to ensure that resident records were retained for R1 for a minimum period of three years, following the termination of services.

During the record review for C#29-AS-20220826155207, the LPA found that the Licensee failed to obtain for S1 a California Clearance or a Criminal Record Clearance as required by the Department, prior to hiring, and allowing staff to be present at the facility. Additionally, the licensee failed to ensure that Personnel Records were obtained, and maintained for S1 for a period of three years. Based on interview with the licensee, the S1 worked at the facility from 08/01/2022 to 08/24/2022. Collateral record review done on 12/27/2022, revealed that S1 was present at the facility, and communicating with the licensee about the residents’ medication as of 07/15/2022. This is a date prior to the S1 being associated with the facility through the Licensing Department. Licensing department record review revealed that the S1 became associated to the facility Blythe Street Elderly Care as of 08/14/2022.

Based on the information obtained, the following deficiencies were observed. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D)



Citations were issued. Exit interview conducted. Today's reports, and appeal rights were reviewed, and issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2022
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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Document Has Been Signed on 12/29/2022 08:01 AM - 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
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: 12/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/06/2023
Section Cited

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87412(a) to (h) Personnel Records. The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement is not met as evidenced by:
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Administrator and licensee will submit Self Certification that they have reviewed title 22 regulations pertaining to staff records.
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Based on records review, the licensee failed to ensure personnel records were maintained, as S1’s personnel records were not available for review by the department, which poses a potential health and safety risk to residents in care.
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Type B
01/06/2023
Section Cited

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87506 (a) (e) Resident Records-The Licensee shall ensure that a separate, complete and current record is maintained for each resident in the facility, and available to licensing agency staff. This requirement is not met as evidenced by:
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Administrator and licensee will submit Self Certification that they have reviewed title 22 regulations pertaining to residents’ records.
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Based on records review, the licensee failed to ensure resident records were maintained at the facility, as R1’sl records were not available for review by the department, which poses a potential 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 PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 12/29/2022 08:01 AM - 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
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: 12/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/06/2023
Section Cited

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81019(e)(1) Criminal Record Clearance. All individuals subject to a criminal record review ... shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by:
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The Licensee agrees to do the following:
Administration will submit Self Certification that they have reviewed the regulations pertaining to Criminal Record Clearance
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Based on record review, the Licensee did not comply with the section cited above, as there was one staff (S1) was working whom were not associated to this facility, 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 PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2022
LIC809 (FAS) - (06/04)
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