<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609725
Report Date: 02/04/2022
Date Signed: 02/04/2022 02:38:29 PM

Document Has Been Signed on 02/04/2022 02:38 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:IVANA MASON HOME INCFACILITY NUMBER:
197609725
ADMINISTRATOR:LIEM, INGEFACILITY TYPE:
735
ADDRESS:7638 MASON AVETELEPHONE:
(818) 648-8118
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 6CENSUS: 5DATE:
02/04/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Inge LiemTIME 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) Pitz conducted an unannounced Case Management visit on this day in order to address a deficiency related to recent building renovations at the facility.

On 1/27/22 the Community Care Licensing Regional Office received notification from the administrator that the facility's floor plan had been changed by erecting a wall to create an additional staff room.

On 2/2/22 the Los Angeles Fire Marshall informed the administrator that the administrator did not obtain the correct building permit prior to the above mentioned modification. The administrator was notified that the facility's fire clearance could only be approved if either the correct building permit is obtained, or the facility is returned to its original state.

On 2/4/22 at 1:15pm LPA Pitz toured the facility and was shown by staff where the additional room was created. The administrator arrived shortly after and stated that the wall was built sometime in November of 2021. LPA observed the facility's building permit to be issued 1/3/22 and state that it is to "Replace drywall/ plaster (patch & paint). Non-structural repair only."


Report reviewed, signed and delivered. Exit interview conducted. Deficiency, civil penalty and appeal rights issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Alexander Pitz
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2022
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 2
Document Has Been Signed on 02/04/2022 02:38 PM - It Cannot Be Edited


Created By: Alexander Pitz On 02/04/2022 at 02:08 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: IVANA MASON HOME INC
FACILITY NUMBER: 197609725

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/07/2022
Section Cited
CCR
800200(a)

1
2
3
4
5
6
7
800200(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator will provide proof of either the correct building permit being obtained from the City, or the facility being restored to its original state.
Civil Penalty of $500 assessed and administrator notified that $100/day to be assessed per HSC 1548(c)(2)(A)
8
9
10
11
12
13
14
Based on the records reviewed and interviews conducted, the facility did not ensure that the correct building permits were obtaine prior to changing the facility's floor plan and requesting a new fire clearance which poses an immediate risk to the health and safety of residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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 Miller
LICENSING EVALUATOR NAME:Alexander Pitz
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2