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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609774
Report Date: 04/13/2022
Date Signed: 04/13/2022 03:02:25 PM


Document Has Been Signed on 04/13/2022 03:02 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
CCLD Regional Office, 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:
04/13/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Nona Khachunts, AdministratorTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Salia Walker conducted an unannounced Case Management- Deficiencies inspection at the facility today, due to deficiencies observed during the subsequent visit of complaint control # 29-AS-20210115115722. At 10:58 a.m., the LPA met with Administrator Nona Khachunts, and explained the reason for the visit.

From 11:00 a.m. until 12:13 p.m., the LPA conducted an interview with the administrator. During the interview conducted with the administrator, the LPA was informed that Resident #1 (R1) passed away. The LPA advised the administrator that CDSS does not have record of R1’s death report, and inquired as to whether the facility submitted the Death Report to Licensing as required per Title 22 Regulations. The administrator stated that the facility submits all death reports, but they have been having technical issues with the facility fax machine. The LPA advised the administrator that a written report/ death report shall be submitted to the licensing agency within seven days of any incident which threatens the welfare, safety or health of any resident. The administrator acknowledged, and stated that the facility will be notifying all incidents pertaining to residents in the future to CCLD.

Pursuant to Title 22 of the California Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Exit interview conducted, today's reports and appeal rights was provided.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022
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 04/13/2022 03:02 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: ST KATHERINE ASSISTED LIVING
FACILITY NUMBER: 197609774

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/13/2022
Section Cited

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87211(a)(1)(A) Reporting Requirements: (a)Each licensee..(1) A written report shall be submitted to the licensing agency..(A) Death of any resident from any cause regardless of where the death occurred..

This requirement is not met as evidenced by:
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Based on record review and interview with the administrator, the licensee failed to comply with the section cited above as the facility failed to submit R1's Death Report as required, which poses a potential health and safety 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: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022
LIC809 (FAS) - (06/04)
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