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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609747
Report Date: 08/18/2022
Date Signed: 08/19/2022 07:34:24 AM


Document Has Been Signed on 08/19/2022 07:34 AM - 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. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:AGNES ASSISTED LIVINGFACILITY NUMBER:
197609747
ADMINISTRATOR:MELIKYAN, NARINEFACILITY TYPE:
740
ADDRESS:7846 AGNES AVETELEPHONE:
(323) 675-8888
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:6CENSUS: 6DATE:
08/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Svetlana PetrosianTIME COMPLETED:
05:30 PM
NARRATIVE
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On 08/18/2022 at 12:00 p.m., Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual inspection with an emphasis on infection control practices and procedures. The LPA met at 1:35 p.m., with Svetlana Patrosian.Facility Representative (FR), and explained the reason for the visit.

Infection Control: Upon entry, the facility has a sign in book, thermometer to take temperature and sanitizing gel. Infection Control signage was visible at the front door.

The LPA and the FR toured the physical plant areas inside, and outside from 1:42 p.m., to 2:10 p.m., to ensure there are no health and safety hazards, and facility is in compliance with Title 22 Regulations.

Kitchen: The LPA and the FR observed the kitchen/dining area. Knives are stored in a locked cabinet. Kitchen appliances were in operable condition. The facility has enough supply of perishable and non-perishable food. Freezer and refrigerator are stocked with a variety of foods. Emergency food supply is adequate for residents and staff. Medication cabinet is locked, and medication has a seven-day supply.

Bedrooms: The LPA and the FR observed the residents’ bedrooms. Bedrooms were furnished appropriately, appropriate furnishings, clean linens and sufficient lighting.

Bathrooms: The LPA and FR observed two restrooms Restroom #1, and Restroom #2. Restroom #1 which is located between the office room, and the staff’s room, was observed to lack paper towels for drying hands. A bottle of dishwashing soap was present in the bathroom sink. The FR stated that it was Dial soap, and that they had put the soap in the dishwashing bottle because the hand washing soap bottle was too small, and kept falling off the sink. The bathroom bottom wood molding near the shower area was found to be black in appearance and have mold. The wood molding by the sink area was brown in color, and appear to have water damage. Restroom #2 lacked paper towels and hand soap. The shower door was down, and leaning in the bathtub against the wall. Additionally, a pillow and other items were inside the bathtub.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2022
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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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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: AGNES ASSISTED LIVING
FACILITY NUMBER: 197609747
VISIT DATE: 08/18/2022
NARRATIVE
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Common areas: The LPA and FR observed the living room and dining room areas were observed to be in clean condition.

Outdoor Space: The LPA and FR observed the outdoor space. Double door, bottom rail leading to the side patio area, is missing part of the plastic, which poses a potential risk to residents in care. A side shaded patio area is available for residents; debris, and a wooden plank was found in the corner of this area, which needs to be removed and disposed of. Back door leading to the backyard had a deactivated sound system. Left hand side corridor leading to the front of the facility was observed to have shopping cart with items (luggage and a plank of wood) inside the cart. Side gates are unlocked. Side gate leading to outdoors is adapted with sound system to alert staff of any elopement.

Residents and Staff Records: The LPA reviewed staff, and residents’ records. Two, out of six residents’ files were not available. Staff: One, out of three staff’ files were not available for review.



The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

The following deficiencies are observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Deficiencies were cited at this time. Exit interview conducted. Signatures obtained. A copy of report was issued.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/19/2022 07:34 AM - 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. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: AGNES ASSISTED LIVING
FACILITY NUMBER: 197609747

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/18/2022
Section Cited

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80087(g) ... "Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients" ... , This requirement is not met as evidenced by:
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Based on observation, cleaning solutions were not locked in an inaccessible place, which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
08/31/2022
Section Cited

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87303 (a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by:
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Based on observation, shower door is broken, wood molding has mold and water damage, patio door bottom partially missing, which poses a potential health, safety or personal rights risk to persons 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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4


Document Has Been Signed on 08/19/2022 07:34 AM - 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. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: AGNES ASSISTED LIVING
FACILITY NUMBER: 197609747

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/26/2022
Section Cited

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87412(a)(1-13)Personnel Records. Personnel records shall be maintained on the licensee, administrator and each employee, and shall contain specified information. This requirement is not met as evidenced by:
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Based on record review, while conducting review of staff records, LPA observed that staff #1 file was missing, which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
08/26/2022
Section Cited

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87506(a)87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by:
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Based on record review, the licensee failed to comply with the section cited above, as resident #1 (R1), and resident #2(R2) two out of six residents did not have a completed facility file which poses a potential health, safety and personal rights 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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4