197609774-7-27-2023-29-AS-CYEE-CU5VWX-20230727164837

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609774
Report Date: 07/27/2023
Date Signed: 07/27/2023 04:48:45 PM

Document Has Been Signed on 07/27/2023 04:48 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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ST KATHERINE ASSISTED LIVING		FACILITY NUMBER:	197609774
ADMINISTRATOR:	NONA KHACHUNTS		FACILITY TYPE:	740
ADDRESS:	6862 KATHERINE AVENUE		TELEPHONE:	(818) 422-0245
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY:	6	CENSUS: 5	DATE:	07/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:04 AM
MET WITH:	Nona Khachunts, Administrator		TIME COMPLETED:	05:00 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) Christine Yee conducted an unannounced Annual Inspection using the complete CARE Inspection Tool. LPA Yee was let into the home by Nvard Manukian, Staff. Nona Khachunts, Administrator was contacted via telephone and arrived at 9:41am to conduct the visit. 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 in bedroom #4. The following was observed on today's visit: the facility has a land line phone and the number provided is (818)285-8639 the living room and dining room is furnished with the appropriate furniture and seating for 6 residents. the kitchen has a dishwasher, stove and refrigerator. knives are locked in a kitchen drawer located in the kitchen is the linen closet with extra bed linens. Perishable and Non-perishable foods meeting Title 22 requirements were observed adjacent to the kitchen is the laundry room which houses a washing machine and dryer, cleaning solutions, toilet paper and additional breakfast foods. also located behind the laundry is a full bathroom with a shower stall designated for staff use. located in the kitchen is a fire extinguisher that was purchased on 6/9/23 and one in the dining room purchased on 6/6/23. Client files and centrally stored medications are stored in the office/staff room Bedroom #1 and Bedroom #4 are shared rooms with 2 hospital beds, 2 night stands, 2 lamps, 2 chairs, a closet and a shared dresser. Bedroom #4 is fire cleared for 1 bedridden resident. Located in Bedroom #4 is also a private bathroom with a shower stall and a bath tub. Grab bars, a non-skid mat

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ST KATHERINE ASSISTED LIVING	FACILITY NUMBER: 197609774
	VISIT DATE: 07/27/2023

NARRATIVE

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and shower chair was observed. Water temperature was tested and had water readings of 112.4 and 111.9 degrees Fahrenheit.
bedroom #2 and Bedroom are private rooms with 1 hospital bed, 1 night stand, 1 chair, 1 lamp, a closet and a shared dresser.
the common bathroom was observed with a shower equipped with grab bars, non-skid mats and shower chair. Water temperature was initially tested at 2:01pm and read 126.2 degrees Fahrenheit. Water temperature was re-tested at 2:33pm and read 124.6 degrees Fahrenheit. Extra bath towels were stored in the cupboards.
first Aid kit and first aid manual with Title 22 requirements were observed.
the interconnected smoke/carbon monoxide detectors were tested and were operational.
posters were observed posted in the staff room, living room and by front door.
front yard was observed to be clean. The lids of the blue and green trash cans were observed to be cracked and had holes
the backyard was observed with covered patio and furnished with a long table and 6 chairs. Wood stored by the storage shed and bucket needs to be discarded and the hospital bed stored along the back side of the home needs to be stored away.
Staff files reviewed had current first aid cards
Administrator certificate expired on 4/2023 but CEUs were submitted and current certificate is pending due to backlog.

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

Exit interview was conducted, APPEALS RIGHTS discussed and a copy was provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 07/27/2023 04:48 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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ST KATHERINE ASSISTED LIVING	FACILITY NUMBER: 197609774
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C) This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in 2 out 2 tests conducted for the water temperature taken in common bathroom read 126.2 degrees Fahrenheit at 2:01pm. Water was re-tested at 2:33pm and the water temperature in the common bathroom read 124.6 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/28/2023
	Plan of Correction
1 2 3 4	The Licensee will immediately adjust the water heater thermostat to reduce the water temperature to Title 22 requirements ranging between 105 degrees to 120 degrees Fahrenheit. Provide evidence that the deficiency has been corrected by 7/28/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 07/27/2023 04:48 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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ST KATHERINE ASSISTED LIVING	FACILITY NUMBER: 197609774
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

87303 Maintenance and Operation: (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
1 2 3 4	Based on observation the licensee did not comply with the section cited above. the back yard needs general cleaning, Cut up wood, wood plank, white bucket stored by the storage shed and the hospital bed store on the left side of the home i needs to be discarded or stored away, cob webs and little beehive observed under the eaves behind the house needs to be cleaned out, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/03/2023
	Plan of Correction
1 2 3 4	The licensee will conduct generally cleaning to discard all unwanted items and store all unused beds, buckets and remove behive observed on the eaves behind the home and provide evidence that the cleaning has been conducted

Type B

Section Cited

CCR

87303(f)(3)

87303 Maintenance and Operation (f) Solid waste shall be stored and disposed of as follows: (3) All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers; shall be in good repair; shall have external handles; and shall be leakproof and rodent-proof This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 2 out of 3 trash cans observed, the lids were cracked and had holes, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/03/2023
	Plan of Correction
1 2 3 4	The Licensee shall contact the sanitation company and obtain replacement bins for the blue recycling bin and the green compost/organic bin by 8/3/23

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 Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

LIC809 (FAS) - (06/04)

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