197609778-7-20-2023-29-AS-CYEE-CTX2NQ-20230720173308

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609778
Report Date: 07/20/2023
Date Signed: 07/20/2023 05:33:19 PM

Document Has Been Signed on 07/20/2023 05:33 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:	YOUR HOME ASSISTED LIVING		FACILITY NUMBER:	197609778
ADMINISTRATOR:	AVETISYAN, ARMENUHI		FACILITY TYPE:	740
ADDRESS:	7022 MATILIJA AVENUE		TELEPHONE:	(818) 983-2224
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY:	6	CENSUS: 4	DATE:	07/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Armenuhi Avetisyan, Administrator		TIME COMPLETED:	05:45 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 required Annual Inspection using the complete CARE inspection tool. LPA Yee was let into the home by Mirna Apkarian, Staff. Staff contacted Armenuhi Avetisyan, Administrator via telephone and she arrived at 9:55am to conduct the visit. The reason for today's visit was provided. The facility is a single storey home consisting of a living room, dining room, kitchen, 3 resident bedrooms, 2 common bathrooms, a staff room and a attached garage. The home is fire cleared for 5 non-ambulatory and 1 bedridden in Bedroom #1 The following was observed on today's visit: The living room and dining room had the appropriate sitting, The fire place was uncovered. A fire extinguisher located in the living room was purchased on 5/23/23 and the one located in the dining room was purchased on 7/11/23. The kitchen had the appropriate refrigerator, stove, microwave, dishwasher. The cleaning solutions were stored in a locked cabinet under the sink and the medications are stored in a locked kitchen cabinet. Sufficient perishable and non-perishable foods were observed and additional foods were purchased during today's visit. Bedroom #1(private) has a hospital bed, 2 night stands and lamps, a chair but had no dresser Bedroom #2 contains 2 hospital beds of which one was observed with a full bed rail for a hospice resident, 2 night stands, 2 lamps, 2 chairs and no dresser Bedroom #3 contains 2 hospital beds, 2 night stands, 2 chairs and no dressers The common bathroom located by the front door is designated solely for staff use was observed to be

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

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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Document Has Been Signed on 07/20/2023 05:33 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: YOUR HOME ASSISTED LIVING	FACILITY NUMBER: 197609778
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(d)(7)

Personal Accommodations and Services

(7) Fireplaces and open-faced heaters shall be adequately screened. 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 1 out of 1 count which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/27/2023
	Plan of Correction
1 2 3 4	The licensee will take steps to make the fireplace inaccessible to the residents. Licensee will provide evidence of correction 7/27/23

Type B

Section Cited

CCR

87307(3)(B)

Personal Accommodations and Services (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers. 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 3 out of 3 rooms inspected, the licensee failed to provide the residents with the require chest of drawers whichposes/posed a potential health, safety or personal rights risk to persons in care. Portable or permanent closets and drawer space in the bedrooms for clothing and personal belongings. A minimum of eight (8) cubic feet (.743 cubic meters) of drawer space per resident shall be provided.
	POC Due Date: 07/27/2023
	Plan of Correction
1 2 3 4	The Licensee will provide the residents with the required chest of drawers that meet Title 22 requirements.

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: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

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: YOUR HOME ASSISTED LIVING	FACILITY NUMBER: 197609778
	VISIT DATE: 07/20/2023

NARRATIVE

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clean. The common bathroom located between Bedroom #1 and Bedroom #2 was observed with grab bars and non-skid mat. Water temperature was tested and read 115.1 degrees Fahrenheit.
The staff room was observed to be clean.
The interconnected smoke detectors located in the living room, front door and in the hallway were tested and was operational. The smoke detector located in the living room is the only combined smoke and carbon monoxide detector. Carbon monoxide was operable.
The front and backyard were clean and well maintained. A wooden ramp with wooden rails was observed from the sliding glass door to the covered patio. The backyard patio was furnished with a large table and 6 chairs. Also located in the backyard are propane operated barbecue grills.
No Bodies of water was observed.
Trash cans were observed to be sealed.
Gates located on both sides of the home are not locked
LPA Yee enquired about any changes/alterations that may have been made to the facility and the Administrator denied any changes to the facility.
Facility telephone number was verified - (818)387-8502.
Per review of facility files, there are no physicians orders on file for the medications.

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

Armenuhi Avetisyan had to leave for an appoint at 3:40pm so the Exit interview was conducted with Mirna Apkarian, Staff, 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: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/20/2023 05:33 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: YOUR HOME ASSISTED LIVING	FACILITY NUMBER: 197609778
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(e)(1-4)

87465 Incidental Medical and Dental Care (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. (1) The specific symptoms which indicate the need for the use of the medication.(2) The exact dosage. (3) The minimum number of hours between doses.(4) The maximum number of doses allowed in each 24-hour period. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 4 out of 4 files reviewed, none of the residents have physicians orders on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/27/2023
	Plan of Correction
1 2 3 4	The Licensee will contact the prescribing doctor and obtain copies of the written orders and place them in the residents files. Fax copies of the written orders to LPA by 7/27/23

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: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC809 (FAS) - (06/04)

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