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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609640
Report Date: 03/14/2022
Date Signed: 03/14/2022 08:26:46 PM


Document Has Been Signed on 03/14/2022 08:26 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., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:MIRACLE ASSISTED LIVING FACILITYFACILITY NUMBER:
197609640
ADMINISTRATOR:GAYANE AGHABEKYANFACILITY TYPE:
740
ADDRESS:20648 LONDELIUS STTELEPHONE:
(747) 206-5390
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY:6CENSUS: DATE:
03/14/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:30 PM
MET WITH:Rima Araronyan Administrator designeeTIME COMPLETED:
07:20 PM
NARRATIVE
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An unannounced Case Management Deficiencies visit in conjunction with a subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. The purpose of this visit is to address deficiencies that were identified during the initial 10 day complaint investigation visit and during the course of the investigation that is not related to the complaint control 31-AS-20211116143735.

Upon arrival at approximately 5:50 pm LPM met with Staff who identified herself as Varduhi, however when LPA again asked the staff for her name staff responded that her name was Susan. LPA requested and reviewed photo id for staff and confirmed her name was Susan Nelly Sahakyan. LPA conducted review of the Licensing information system and confirmed that staff's criminal record clearance has not been transferred to this facility.

While conducting a tour of the facility LPA observed that resident 2 (R2) is residing in a room that was designated as a staff room and according to the administrator designee later changed to an ambulatory resident room. At 6:18 pm LPA conducted review of R5's physicians report which documented that resident is non ambulatory.

The administrator designee Rima Araronyan arrived to the facility approximately 6:05 pm. A discussion was held with Ms. Araronyan regarding staff working at the facility. Ms. Araronyan insisted that the staff member is currently in training and has been working at the facility for only 2 days. Ms. Araronyan also stated that the staff member is not left alone with the resident and that she only stepped away from the facility briefly. Approximately 6:32 pm LPA conducted interview with 2 of the residents who confirmed that the staff has been working at the facility for about a week or two and is usually the only staff in the evenings and on weekends.

At approximately 6:40 pm a discussion was held with Ms. Araronyan regarding resident 3 (R3). Per Ms. Araronyan resident is not bedridden and is put in her wheelchair at time., however according to the residents physicians report upon admission to the facility R3 was bedridden.

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022
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 03/14/2022 08:26 PM - 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., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: MIRACLE ASSISTED LIVING FACILITY
FACILITY NUMBER: 197609640

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/16/2022
Section Cited

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(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. This requirement was not met as evidenced by:
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Based on information obtained on 11/17/2021 and interviews the licensee/administrator did not comply with the cited section by operating over capacity. Admitting and retaining 7 residents when their licensed capacity is for 6 residents which posed an immediate health and safety and personal rights risk to clients in care.
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2) Verification of completed training will need to be submitted to the LPA by 3/28/2022.

This is a zero tolerance violation therefore a civil penalty in the amount of $500.00 has been issued. Civil penalties will continue to accrue until plan of correction is submitted.
Type A
03/15/2022
Section Cited

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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). This requirement is not met as evidenced by
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Based on interviews, and record review, the licensee & administrator did not comply with the section cited by allowing S1 to work at the facility prior to transferring her criminal record clearance to this facility. which poses an immediate health and safety risk to residents in care.
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This is a zero tolerance violation therefore a civil penalty in the amount of $500.00 has been issued. Civil penalties will continue to accrue until plan of correction is submitted.
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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/14/2022 08:26 PM - 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., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: MIRACLE ASSISTED LIVING FACILITY
FACILITY NUMBER: 197609640

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/16/2022
Section Cited

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No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.

This Requirement was not met as evidenced by:
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Based on the information obtained by LPA during the 11/17/2021 visit the Administrator designee Rima Araronyan did not comply with he cited section by asking Resident 2 (R2) to provide false/misleading statements to LPA regarding his identity and the room he resides in which posed an immediate personal rights violation to residents in care.
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87405: Administrator Qualifications and Duties.
87408: Denial or Revocation of a Certificate
87777: Exclusions
Personal Rights.
Written statement and verification of scheduled training with the trainers credentials will need to be submitted by 3/16/2022 and completed by 4/1/2022.
Type B
03/16/2022
Section Cited

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(b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met:(4) (A)(B)(C) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident’s medical condition(s)........
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This requirement was not met as evidenced by: Record Review and Interview conducted. The licensee did not comply with the cited section by not completing a written agreement with the home health agency related to the condition and care of the pressure injuries which posed a potential health and safety and personal rights risk to R1.
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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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5


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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MIRACLE ASSISTED LIVING FACILITY
FACILITY NUMBER: 197609640
VISIT DATE: 03/14/2022
NARRATIVE
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At approximately 6:43 pm LPA spoke with R3's roommate who confirmed that the staff repositions R3 and cannot recall the last time that R3 was taken out of bed if ever. R3 is currently residing in a room that has non-ambulatory fire clearance.

During the initial 10 day complaint visit from approximately 9:15 am to 9:25 am LPA conducted a tour of the facility. From 9:30 am to 9:45 am LPA conducted review of the resident files and request copies of pertinent documents. From 9:45 am to 10:10 am LPA spoke with Rima Araronyan Administrator designee. During the visit LPA noted and discussed the following with Ms. Araronyan.
  • Licensee/Administrator retained 7 residents at the facility from 10/29/2021 to 11/15/2021
  • Licensee did not transfer criminal record clearance for Staff 1 (S1). During the 11/17/2021 visit LPA was informed by Ms. Araronyan that she emailed the transfer form to the regional office email. LPA requested for the email to be forwarded to her attention. As of today's visit the email has not been forwarded..
  • Administrator designee Rima Araronyan requested for resident 2 (R2) to provide false/misleading statement to the LPA regarding his status at the facility by telling the resident in Armenian to say he is the husband of the female staff. Ms. Araronyan also asked R2 to provide false/misleading statement to the LPA regarding the room he resides in.
  • The licensee did not obtain/complete an agreement in writing related to the care of R1's pressure injuries. The licensee did not ensure staff receive training from the home health agency for R1's care needs

Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited: (Refer to LIC 809-D). Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 03/14/2022 08:26 PM - 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., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: MIRACLE ASSISTED LIVING FACILITY
FACILITY NUMBER: 197609640

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/15/2022
Section Cited

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All facilities shall maintain a fire clearance. Prior to accepting persons over 60 years of age none ambulatory and/or bedridden the licensee shall notify the licensing agency and obtain an appropriate fire clearance. This requirement is not met as evidenced by: Based on observation, interview and record review, the licensee did not comply
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with the section cited above by retaining 1 bedriddent resident in room with non ambulatory fire clearance and 1 non ambulatory resident in room with ambulatory fire clearance which poses an immediate health, safety or personal rights risk to persons in care.
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Mr. Araronyan will inform the LPA in writing when the moves have been completed and indicate which room the residents were relocated to.
Type B
03/16/2022
Section Cited

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(a) Prior to admission of a resident with a restricted health condition, the licensee shall: (2) (A)(B) Ensure that facility staff who will participate in meeting the resident’s specialized care needs complete training provided by a licensed professional sufficient to meet those needs....
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This requirement was not met as evidenced by: Based on interview and record review the licensee did not comply with the cited section by not ensuring staff providing care to R1 received training related to R1's specialized care needs which posed an immediate health and safety and personal rights risk to R1.
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1) Verification of the scheduled training with the credentials of the trainer will need to be emailed to the LPA by 3/16/2022

2) Verification of completed training will need to be submitted to the LPA by 3/28/2022.
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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022
LIC809 (FAS) - (06/04)
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