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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609766
Report Date: 06/25/2022
Date Signed: 06/25/2022 06:50:53 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/25/2022 06:50 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:HORIZON ASSISTED LIVING FACILITYFACILITY NUMBER:
197609766
ADMINISTRATOR:SONA GEVORKYANFACILITY TYPE:
740
ADDRESS:9708 VALJEAN AVETELEPHONE:
(310) 720-4551
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 5DATE:
06/25/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Sona GevorkyanTIME COMPLETED:
06:55 PM
NARRATIVE
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An unannounced case management Annual Continuation visit in conjunction with a subsequent complaint visit (Complaint Control # 31-AS-20200428160827) was conducted on this day by licensing program analyst (LPA) Yelena Avetisyan. Upon arrival, the LPA met with staff Rosa Tonoyan, who contacted administrator Sona Gevorkyan via telephone. Approximately 1:00 pm Ms. Gevorkyan arrived to the facility.

Approximately 12:37 pm LPA conducted a brief tour of the facility and spoke with Staff. While conducting the tour LPA observed the 2 backyard gates exiting the facility pad locked. When touring the facility LPA observed R1 in Rm # 2 utilizing full bed rails. When asked staff stated that they currently have 4 residents on hospice.

From 2:20 pm LPA conducted review of files for 5 residents. LPA requested to review hospice files for residents however licensee did not have complete hospice files for 4 out of 4 residents who are currently receiving hospice services Licensee did not have hospice care plan for R1 indicating the need for the full rail.
A discussion was held with the administrator about ensuring that a complete hospice file is kept at the facility along with copies of hospice visit reports.

At 4:00 pm LPA conducted review of staff files. While reviewing the staff files LPA observed that licensee/administrator is not documenting staff training properly. Staff 1 does not have medication training since start of employment. Staff #2 received medication training from a hospice RN however the licensee/administrator did not have copy of the test taken, or information regarding the training program that was used to provide the training. Staff 3's medication training was from 2019 and documentation missing same information/documentation as staff 2. A lengthy discussion was held with Ms. Gevorkyan regarding documenting staff training, and the requirements of medication training.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 06/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2022
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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Document Has Been Signed on 06/25/2022 06:50 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: HORIZON ASSISTED LIVING FACILITY
FACILITY NUMBER: 197609766

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/26/2022
Section Cited
CCR
87705(I)(5)

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The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates:
(2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates. This requirement is not being met as evidenced by
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Staff removed the locks from the gates. Licensee/administrator will submit a dated and signed written statement that exit doors will not be pad locked at any time.
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Based on observation and interview the licensee did not comply with the section cited by locking the backyard exit doors/gates of the facility without the approval of the fire department which poses an immediate health and safety and personal rights violation to persons in care.
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This is a zero tolerance violation therefore a civil penalty in the amount of $500.00 has been issued. Civil penalties will continue to accrue until plan of correction is submitted.
Deficiency Dismissed
Type A
06/26/2022
Section Cited
CCR87202(a)(2)

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FIRE CLEARANCE. All facilities shall maintain a fire clearance. Prior to accepting persons over 60 years of age none ambulatory and/or bedridden the licensee shall notify the licensing agency and obtain an appropriate fire clearance.

This requirement is not met as evidenced by:
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Licensee/Administrator will submit a dated, signed written statement notifying the department how this deficiency will be corrected.
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This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited by retaining bedridden resident in room with non ambulatory fire clearance (R1)which poses an immediate health, safety and personal rights risk to R1.
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This is a zero tolerance violation therefore civil penalty in the amount of $500 has been issued. Civil penalties in the amount of $100 dollars per day will accrue until POC is received.
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 MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 06/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HORIZON ASSISTED LIVING FACILITY
FACILITY NUMBER: 197609766
VISIT DATE: 06/25/2022
NARRATIVE
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From approximately 5:12 pm LPA observed as staff provided assistance to R1. LPA observed R1 required the assistance of 2 staff to sit up in bed, stand from bed and required physical assistance by staff to sit on the wheelchair and reposition body to be able to sit on the wheelchair. Based on LPA observations resident appears to be bedridden and currently residing in a room that has ambulatory fire clearance.

LPA requested the following documents to be submitted to the Woodland Hills RO by 6/27/2022

Initial/Comprehensive Hospice Assessment for all 4 residents. Administrator will also work with the hospice agency to obtain and retain complete and up to date hospice files for all residents at the facility.
To ensure hospice care plan for R1 specifies the need for the full rails.
Documentation regarding the medication training provided to Resident by Hospice RN. The administrator understands if the training provided was not compliant with the regulations she will schedule vendorized medication training for all staff.
Copy of current liability insurance
Current LIC 500.

Exit interview conducted, copy of report, citations and civil penalties issued.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2022
LIC809 (FAS) - (06/04)
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