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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609774
Report Date: 07/25/2024
Date Signed: 07/25/2024 05:15:26 PM


Document Has Been Signed on 07/25/2024 05:15 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:ST KATHERINE ASSISTED LIVINGFACILITY NUMBER:
197609774
ADMINISTRATOR:NONA KHACHUNTSFACILITY TYPE:
740
ADDRESS:6862 KATHERINE AVENUETELEPHONE:
(818) 422-0245
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY:6CENSUS: 6DATE:
07/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Nona Khachunts, AdministratorTIME COMPLETED:
05:20 PM
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Licensing Program Analyst (LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool. LPA Yee was let into the home by Nvard Manukian, staff. Nana Khachunts, Administrator, was contacted by staff and she arrived at 10:47am to conduct the visit. The reason for today's visit was provided.

The facility is a single storey family home consisting of a living room, dining room, kitchen, 4 resident bedrooms, an office/staff room, 3 full bathrooms, laundry room and a attached garage. The facility is fire cleared for 5 non-ambulatory residents and 1 bedridden resident. Bedroom #4 is approved for a bedridden resident.

The following were observed on today's visit:
  • the living room, dining room, and kitchen were equipped with the appropriate furnishings and equipment. A fire extinguisher was observed in the dining room and one in the kitchen. Both fire extinguishers were purchased on 6/19/24.
  • sufficient perishable foods for a minimum 2 days and non-perishable foods for a minimum of 7 days were observed maintained on the premises
  • bedroom #1 and Bedroom #4 are furnished with 2 each: beds, chairs, night stands, lamps and a shared closet and dresser. Bedroom #4 has French doors and the blinds need to be repaired/replaced.
  • bedroom #2 and #3 are single rooms and are furnished with a bed, a chair, night stand, lamp, a dresser and a closet.
  • the common bathroom is equipped with a shower stall, a sink, a toilet and storage cabinets. Grab bars and non-skid mat was observed. Water temperature was tested and read 119.6 degrees Fahrenheit
  • the private bathroom located in bedroom #4 contains a toilet, tub, a shower stall with grab bars and a non-skid mat. Water temperature was tested and read 111.1 degrees Fahrenheit.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ST KATHERINE ASSISTED LIVING
FACILITY NUMBER: 197609774
VISIT DATE: 07/25/2024
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  • medications are centrally stored in a locked cabinet in the office
  • cleaning solutions and laundry detergent are stored in the locked laundry room. Toilet tissue were also observed
  • knives are stored in a locked kitchen drawer.
  • the 3rd bathroom located by the laundry room is designated for staff use.
  • the resident beds were observed with a mattress cover and fitted sheet. A flat sheet and a blanket were observed placed at the foot of the bed due to the heat.
  • extra blankets, linens, towel, comforters were observed in the linen closet.
  • the hardwired combination smoke/carbon monoxide detectors were tested and were operational
  • per review of staff files, all staff have first aid cards.
  • the Administrator has a current Administrator Certificate.
  • the backyard is completely enclosed.
  • the back of the home has a ramp leading from the living room.
  • the back has a covered patio furnished with a long table and 6 chairs.
  • The front and the backyard were observed to be clean and free of clutter.
  • The trash cans were observed to be in good condition and were tightly sealed

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8

Exit interview was conducted with Agavni Saakyan, Staff, since the Administrator had to leave during the visit.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/25/2024 05:15 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: ST KATHERINE ASSISTED LIVING
FACILITY NUMBER: 197609774

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above as per information provided that the facility does not have current liability insurance since the insurance premiums went up and the licensee is looking for cheaper rates which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2024
Plan of Correction
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Licensee will purchase liability insurance which meets Health and Safety/Title 22 requirements and provide the Department with evidence that the required liability insurance has been purchased by 8/1/24.
Type B
Section Cited
CCR
87303(a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above per tour of Bedroom #4, it was observed that the vertical slates of the blinds on the French door were falling off the hooks which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2024
Plan of Correction
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Licensee will either replace the vertical slates or replace the blinds on the French door located in Bedroom #4 and provide evidence of correction by 8/1/24.
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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024
LIC809 (FAS) - (06/04)
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