197609675-4-17-2025-31-AS-MAGN-DFTUYT-20250417160029

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609675
Report Date: 04/17/2025
Date Signed: 04/17/2025 04:02:10 PM

Document Has Been Signed on 04/17/2025 04:02 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	HIGHLANDS MANOR INC		FACILITY NUMBER:	197609675
ADMINISTRATOR/ DIRECTOR:	LEVIN, RUSLAN		FACILITY TYPE:	740
ADDRESS:	9811 BELMAR AVE		TELEPHONE:	(747) 206-5436
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	04/17/2025
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:38 PM
MET WITH:	RUSLAN LEVIN- Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced continuation of the annual visit. The LPA met with Administrator Ruslan Levin and explained the reason for the visit. During today's visit, the LPA reviewed files for three (3) residents to ensure compliance with licensing forms. LPA observed that R3 has an incomplete Admission Agreement and lacks appraisal needs and services (LIC 603A). Additionally, R4 and R5 have no updated physician report (LIC 602). LPA also conducted a review of staff records to ensure that forms and training are current and comply with licensing requirements. LPA noted that S2 and S3 are missing the LIC 503 forms. The administrator advised that all required forms will be emailed to LPA Agban promptly. Finally, LPA conducted a review of medication records. The LPA found that medications and medication records were inconsistent. Exit interview conducted, citations issued, appeal rights given and copy of this report delivered.

Eva Miller	TELEPHONE: (818) 596-4373
Mariana Agban	TELEPHONE: 818-738-4525
	DATE: 04/17/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 04/17/2025 04:02 PM - It Cannot Be Edited

Created By: Mariana Agban On 04/17/2025 at 02:40 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HIGHLANDS MANOR INC	FACILITY NUMBER: 197609675
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. S2 and S3 are missing LIC 503 forms which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/01/2025
	Plan of Correction
1 2 3 4	Administrator agreed to provide LIC 503 for S2 and S3 by the POC date.

Type B

Section Cited

CCR

87465(d)(2)

Incidental Medical and Dental Care Services

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) The date and time of each contact with the physician, and the physician's directions, shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review the licensee did not comply with the section cited above. LPA observed medication records for 5 out 5 residents were inconsistent which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/01/2025
	Plan of Correction
1 2 3 4	The administrator agreed to audit medications to ensure consistency in the medication records. Administrator will email LPA proof of medication audit by the POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Eva Miller
NAME OF LICENSING PROGRAM MANAGER:

TELEPHONE: (818) 596-4373

	Mariana Agban
NAME OF LICENSING PROGRAM ANALYST:

TELEPHONE: 818-738-4525

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/17/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 04/17/2025 04:02 PM - It Cannot Be Edited

Created By: Mariana Agban On 04/17/2025 at 02:40 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HIGHLANDS MANOR INC	FACILITY NUMBER: 197609675
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(b)(15)

Resident Records

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above. LPA observed that R3 has incomplete admission agreement which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/01/2025
	Plan of Correction
1 2 3 4	Administrator will provide completed Admission Agreement by the POC date.

Type B

Section Cited

CCR

87458(c)(1)

Medical Assessment

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above. LPA observed R4 and R5 do not have updated medical assessment which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/01/2025
	Plan of Correction
1 2 3 4	Administrator will provide updated medical assessment for R4 and R5 by the POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Eva Miller
NAME OF LICENSING PROGRAM MANAGER:

TELEPHONE: (818) 596-4373

	Mariana Agban
NAME OF LICENSING PROGRAM ANALYST:

TELEPHONE: 818-738-4525

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/17/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 04/17/2025 04:02 PM - It Cannot Be Edited

Created By: Mariana Agban On 04/17/2025 at 02:40 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HIGHLANDS MANOR INC	FACILITY NUMBER: 197609675
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(a)

Reappraisals

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. LPA observed R3 does not have appraisal needs and services plan which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/01/2025
	Plan of Correction
1 2 3 4	Administrator will provide an appraisal needs and services plan for R3 by the POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Eva Miller
NAME OF LICENSING PROGRAM MANAGER:

TELEPHONE: (818) 596-4373

	Mariana Agban
NAME OF LICENSING PROGRAM ANALYST:

TELEPHONE: 818-738-4525

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/17/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

LIC809 (FAS) - (06/04)

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