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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609639
Report Date: 05/29/2024
Date Signed: 05/30/2024 07:37:30 AM


Document Has Been Signed on 05/30/2024 07:37 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:ANA'S RESIDENCE CARE FACILITYFACILITY NUMBER:
197609639
ADMINISTRATOR:ANNA ATAYANFACILITY TYPE:
740
ADDRESS:7747 VAN NOORD AVETELEPHONE:
(323) 688-3377
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:6CENSUS: 5DATE:
05/29/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Anna AtayanTIME COMPLETED:
05:05 PM
NARRATIVE
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During the complaint investigation of complaint #29-AS-20240118120829, the following deficiencies were observed:

Staff failed to seek medical attention for Resident #1 (R1) in a timely manner. The licensee/administrator and staff reported R1 complained of abdominal and back pain. The licensee/administrator called R1’s resident representative and told them to call an ambulance because R1 was not well. R1’s resident representative came to the facility and observed R1 was in “excruciating pain” and would scream when R1 was moved or tried to move. R1’s resident representative then took R1 to the hospital. Medical records showed R1 sustained a T11 compression fracture. R1 reported Staff #1 (S1) “dropped” R1. The licensee/administrator and staff failed to call 911 or R1’s doctor to seek medical attention for R1.

Staff #1 (S1) advised they were a caregiver at the facility for approximately one week. The licensee/administrator reported that S1 worked at the facility from 01/01/2024 to 01/13/2024. S1 was covering for a caregiver who was on vacation. S1 was fingerprint cleared but was not associated to work at the facility. An Immediate $500 Civil Penalty is assessed today.

A review of the Palermo hospice medical records indicated R1 was placed on hospice care at the facility on 01/11/2024. There is no evidence or confirmation that the hospice notification was submitted to Community Care Licensing (CCL).
Citations issued, Immediate $500 Civil Penalty issued, exit interview, appeal rights given.
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
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 3


Document Has Been Signed on 05/30/2024 07:37 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: ANA'S RESIDENCE CARE FACILITY
FACILITY NUMBER: 197609639

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/14/2024
Section Cited
CCR
87465(a)(1)

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87465(a)(1) Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
This requirement is not met as evidenced by:
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The licensee will submit a plan describing how you will ensure residents will receive timely medical care. Submit proof to CCL by 06/14/2024.
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Based on interviews and medical records, the licensee did not comply with the section cited above. The licensee/administrator or staff did not seek medical attention when R1 complained of abdominal and back pain, which posed an immediate health and safety risk to residents in care.
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Type A
06/14/2024
Section Cited
CCR87355

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87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(2) Request a transfer of a criminal record clearance as specified in Section 87355(c). (f) Violation of Section 87355(e) shall result in an immediate assessment of civil penalties of one hundred dollars ($100) per violation per day for a maximum of five (5) days by the department.
This requirement is not met as evidenced by:
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The licensee will submit a plan describing how you will ensure staff are fingerprint cleared and associated to the facility prior to working. Submit proof to CCL by 06/14/2024.

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Based on interviews and record review, the licensee did not comply with the section cited above. S1 was not associated to the facility yet worked at the facility from 01/01/2024 to 01/13/2024, which posed an immediate health and safety risk to residents in care. Immediate $500 civil penalty assessed.

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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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 05/30/2024 07:37 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: ANA'S RESIDENCE CARE FACILITY
FACILITY NUMBER: 197609639

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/07/2024
Section Cited
CCR
87632(d)(2)

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Hospice Care Waiver (d)(2)If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver as necessary to ensure the well-being of terminally ill residents and of all other facility residents, which shall include…the following requirements: (2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility…This requirement is not met as evidenced by:
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The licensee will submit a plan describing how you will ensure notification of the initiation of hospice care services is met within the required time frame. Submit proof to CCL by
06/07/2024.
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Based on records review, the licensee did not comply with the section cited above. There is no evidence or confirmation that the licensee submitted a notification for R1’s 01/11/2024 initiation of hospice care services, which posed 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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3