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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609774
Report Date: 06/19/2024
Date Signed: 06/19/2024 11:32:19 AM


Document Has Been Signed on 06/19/2024 11:32 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
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:
06/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:08 AM
MET WITH:Nona Khachunts, AdministratorTIME COMPLETED:
11:40 AM
NARRATIVE
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Licensing Program Analyst(LPA) conducted a case management visit due to the deficiencies observed during the investigation of complaint #29-AS-20230630104441. LPA Yee met with Nona Khachunts, Administrator and the reason for the visit was explained.

The following deficiencies were observed:
  • Resident #1 (R1) who was receiving hospice care services, was admitted to the Sherman Oaks Hospital on 06/23/2023 due to a decline in health and unresponsive. The administrator indicated that R1 did not return to the facility due to passing away at the hospital. There was no death report submitted to Community Care Licensing (CCL). The failure of the facility to report the fall of Resident #1 was addressed through the complaint.
  • Resident #1 was receiving hospice care services prior to being hospitalized due to the fall and the facility failed to notify CCLD of initiation of hospice care services within the required 5 days noted as a condition for the hospice waiver granted.



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

Exit interview was conducted, Appeals Rights discussed and copy was provided with this report.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024
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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Document Has Been Signed on 06/19/2024 11:32 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
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: 06/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/21/2024
Section Cited
CCR
87211(a)(1)(A)

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Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence. This report
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Licensee will ensure that all deaths are reported to the Department within 7days. Licensee will submit a death report for R1 listing date of death and cause of death, along with a copy of the death certificate to CCL by due date of 6/21/24
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should include resident's name, age, sex, date of admission,date and nature of event..(A)Death of any resident from any cause regardless of where the death occurred, including but not limited to… a hospital, in route to or from a hospital, or visiting away from the facility. R1's death was not reported to the Department
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Type B
06/21/2024
Section Cited
CCR87632(d)(2)

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If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver as necessary to ensure the well-being of terminally ill residents and of all other facility residents, which shall include, but not be limited to, the following requirements: The licensee shall notify
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Licensee will review Titile 22 Section 87632 -HOSPICE CARE WAIVER and submit a signed statement that the section was read and understood. Licensee will submit initiation of hospice care services notification letters for all residents who are receiving hospice care services by 6/21/24
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the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice.
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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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024
LIC809 (FAS) - (06/04)
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