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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609689
Report Date: 07/23/2024
Date Signed: 07/23/2024 08:02:51 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/23/2024 08:02 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
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: 3DATE:
07/23/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jassman Geragossian, Caregiver TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Leizl de la Cerra conducted an unannounced continuation of the annual visit from July 11, 2024. At 11:00AM Jassman Geragossian, caregiver greeted LPA at the entrance and LPA explained the reason for the visit. Jassman contacted the administrator, Gayane Agazaryan by phone. After Jassman spoke with administrator, Jassman informed LPA that administrator will not be available, because the administrator is at the hospital due to a knee problem. The administrator was not available either on the previous visit for annual inspection on July 11, 2024.At 11:15AM, required records were requested.
Resident and Staff Records reviews: At approximately 11:45AM to 1:45PM, three (3) out three (3) resident records and four (4) staff records were reviewed to ensure compliance. Fire Clearance was approved on 01/17/2019 for five (5) non-ambulatory residents and one (1) bedridden in bedroom #2. All four (4) bedrooms are designated for resident use. Facility approved for five (5) hospice waivers. During staff records review LPA observed staff (S1) who was present at the facility giving care to residents, did not have a staff file. S1 did not have a fingerprint clearance and is not associated with the facility.
At 2:00PM LPA with the assistance of the caregiver, took a tour of the facility.
Common Area: LPA observed the living room and furniture to be clean and in good repair. The fireplace located in the living room is adequately closed and inaccessible to residents. The facility maintains a comfortable temperature at 76 degrees Fahrenheit. The air conditioner is operational. The facility smoke alarm system is hard wired and interconnected. The facility uses a dual Carbon Monoxide/Smoke alarm detectors all over the common areas of the facility. At 2:15PM they were tested and deemed operational. Facility maintains a telephone land line and it was observed to be operational. Required postings were observed in the hallway. Each exit features a functioning auditory alarm. There were two (2) fire extinguishers, one in the kitchen area and one in the common area, both inspected on 4/02/2024. The facility is fire cleared for six (06) non-ambulatory residents; one (1) maybe bedridden in bedroom #2 approve for four (4) hospice waiver.

Continued to LIC 809-C

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Leizl De La CerraTELEPHONE: (818) 454-0632
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
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 4


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
VISIT DATE: 07/23/2024
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Kitchen: The kitchen appliances were functional. The kitchen has a working stove, faucet, refrigerator, and microwave. LPA observed enough food for at least three (3) days perishable and seven (7) days of non-perishable food at the facility which were all properly stored. Knives were stored in a locked drawer in the kitchen. Food preparation areas are clean. Garbage can has a tight fitting cover. Residents' dining table fits enough for six (6) people.
Bedrooms: There are four (4) bedrooms that were properly furnished with appropriate dresser, night stand, lamp, chair, beddings, and linens. Extra linens, towels and beddings are stored in the hallway closets. Bedroom #1 and bedroom #3 is currently vacant.
Bathrooms: There are two (2) bathrooms designated for residents use. The bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 111.8 degrees and 109.6 degrees Fahrenheit.
Surrounding Grounds: There is a patio furniture with a cover, appropriate for outdoor use. The outdoor area was free of hazards. The facility does not have any bodies of water.
Garage: The garage is attached and is accessible through the kitchen. LPA requested to observed the garage, the caregiver unlocked the door to the garage. Facility has a washer and dryer located inside the garage. The garage is also used for storing extra food supplies, toiletries, PPE supplies, and incontinence supplies. Laundry chemicals are also stored in the garage. The garage will remain locked and inaccessible to residents in care.

LPA observed a 4 drawer locked cabinet in the kitchen area that contains all the residents' records, the staff records and the residents' medications. LPA observed each of the drawers to have separate locks, which is inaccessible to residents in care. First aid kit was missing a current or updated manual.

Pursuant to Title 22 regulations, citations were issued and recorded on LIC809D. Exit Interview was conducted. Appeal rights was provided. A copy of the report provided.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Leizl De La CerraTELEPHONE: (818) 454-0632
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/23/2024 08:02 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: 07/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/24/2024
Section Cited
CCR
87355(e)(1)

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87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review... shall prior to working, in a licensed facility(1)Obtain a California clearance criminal record exemption as requiredt.This requirement is not met as evidenced by:
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Administrator will submit for a criminal background clearance for S1 to the Department. A copy of the request will be emailed to LPA by POC date.
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Based on file review, the licensee did not comply with the section cited above for staff 1 (S1) who is a personal assistant for the resident (R1) at the facility.This poses an immediate health & safety risk to the residents in care.
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Type B
07/30/2024
Section Cited
CCR87412(a)

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87412(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:
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Administrator will provide a copy of a complete staff file for S1 by POC date.
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Based on observations and interviews, the facility did not ensure that a staff file was maintained at the facility for S1 who is there daily at least 6 hrs per day which poses a potential health and personal right 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: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 07/23/2024 08:02 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: 07/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/30/2024
Section Cited
CCR
80075(g)(1)(A)

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80075 Health Related Services (g) first aid supplies shall be available in facility.(1)The supplies shall include:(A)Current 1st aid manual approved by American Red Cross, American Medical Assoc or state/federal agency.
This requirement is not met as evidenced by:
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Administrator will provide by email a reciept of the purchaed First Aid Manual to LPA by POC date,
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Based on observation, facility first aid supply kit did not have a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency.
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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: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
LIC809 (FAS) - (06/04)
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