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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609615
Report Date: 03/04/2021
Date Signed: 03/04/2021 12:10:42 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:MOONLIGHT ELDERLY CAREFACILITY NUMBER:
197609615
ADMINISTRATOR:SAROUKHANYAN, DAVIDFACILITY TYPE:
740
ADDRESS:13021 KESWICK STREETTELEPHONE:
(747) 444-6246
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:6CENSUS: 0DATE:
03/04/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Sandy Khambekyan - AdministratorTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Brian Balisi conducted a case management visit virtually with Administrator Sandy Khambekyan due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures.

On 2/5/2021 LPA spoke with Sandy who stated that she will be closing the facility. LPA advised Sandy to reference HSC 1569.682 for closing procedures. Census was (2) at that time.  On 2/18/2021 - LPA received an email from Sandy detailing the relocation of the (2) residents. LPA observed no eviction notices were issued.

During today's visit, LPA toured the facility and observed that there were no clients residing in the facility. Licensee stat that they will mail the facility license to Community Care Licensing Woodland Hills office.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

A telephonic exit interview was conducted with the licensee, and a hard copy was provided via email for signature.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021
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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MOONLIGHT ELDERLY CARE
FACILITY NUMBER: 197609615
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/05/2021
Section Cited

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Transfer of resident upon forfeiture of license or change in use of facility; duties of licensee; closure plan; duty of department upon licensee’s failure to comply; civil penalties.(a) A licensee of a licensed residential care facility for the elderly shall, prior to transferring a resident of the facility to another facility...
This requirement is not met as evidenced by:
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Based on LPA's observations, the licensee did not comply with the section cited above as eviction letters were not issued to the residents 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2021
LIC809 (FAS) - (06/04)
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