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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609689
Report Date: 07/11/2024
Date Signed: 07/11/2024 05:21:29 PM


Document Has Been Signed on 07/11/2024 05:21 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:HOLLYWOOD HEALTHY LIVING LLCFACILITY NUMBER:
197609689
ADMINISTRATOR:AGAZARYAN, GAYANEFACILITY TYPE:
740
ADDRESS:8002 HOLLYWOOD WAYTELEPHONE:
(818) 395-1905
CITY:SUN VALLEYSTATE: CAZIP CODE:
91352
CAPACITY:6CENSUS: 5DATE:
07/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Jasmin Geragossian, CaregiverTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Leizl de la Cerra conducted an unannounced annual visit of the facility. At 2:45PM Jasmin Geragossian, who stated that she was a caregiver at the facility, greeted LPA at the entrance and LPA explained the reason for the visit. Jasmin contacted the administrator, Gayane Agazaryan, who was not present at the facility. LPA was informed that administrator will not be available.

LPA De La Cera spoke with administrator over the phone and requested for the staff files and the residents' files. LPA was informed by the administrator that staff files are not in the facility. Staff files were removed out of the facility by the administrator in order for administrator to arrange and update the files.

Due to unavailability of the staff files, LPA will continue the annual visit at a later time.

Facility was issued a citation. Refer to LIC809-D.

Exit interview conducted and a copy of the report was signed by caregiver. Copy of report was issued..



SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Leizl De La CerraTELEPHONE: (818) 454-0632
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024
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 07/11/2024 05:21 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: HOLLYWOOD HEALTHY LIVING LLC
FACILITY NUMBER: 197609689

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/12/2024
Section Cited
CCR
87412(g)

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87412 Personnel Records
(g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.
This requirement was not met as evidenced by:
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Administrator to submit to the Department a complete personnel file of every staff member employed at the facility by 7/12/24.
Administrator to submit a signed certification to the Department by 7/12/24 that completed personnel files shall be accessible and remain in the facility at all times.
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The Licensee removed personnel records/files of each staff out of the facility and licensing agency was unable to review personnel records/files. This 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: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Leizl De La CerraTELEPHONE: (818) 454-0632
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024
LIC809 (FAS) - (06/04)
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