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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609778
Report Date: 07/30/2024
Date Signed: 07/30/2024 05:47:29 PM


Document Has Been Signed on 07/30/2024 05:47 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:YOUR HOME ASSISTED LIVINGFACILITY NUMBER:
197609778
ADMINISTRATOR:AVETISYAN, ARMENUHIFACILITY TYPE:
740
ADDRESS:7022 MATILIJA AVENUETELEPHONE:
(818) 983-2224
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY:6CENSUS: 5DATE:
07/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Armenuhi Avetisyan, AdministratorTIME COMPLETED:
05:55 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 Mirna Apkarian, Staff. Armenuhi Avetisyan, Administrator was contacted by telephone and she arrived at 11:31am to conduct the visit.

The facility is a single storey home consisting of a living room, dining room, kitchen, 3 resident bedrooms, 2 common bathrooms of which one is designated for staff use, a staff room and a attached garage. The home is fire cleared for 5 non-ambulatory and 1 bedridden. Bedroom #1 is approved for bedridden use.

On today's visit all 12 domains of the Care Inspection Tool was reviewed, 5 resident and 6 staff files were reviewed. The following were observed:
  • the living room, dining room and kitchen were toured and contained the appropriate furnishings and equipment
  • the fire place in the living room was made inaccessible with a square piece of dry wall and recommendation was made to include a fire screen.
  • a fire extinguisher was observed in the dining room and one in the dining room. Both were purchased on 1/11/24.
  • Bedroom #1 was observed with a single hospital bed with a half bed rail, a chair, a lamp, 2 night stands, a shared closet and no dresser at the request of the resident.
  • Bedroom #2 was observed with 2 hospital beds with full bed rails, 2 night stands, 2 lamps, a shared dresser and no chairs due to use of wheelchairs.
  • the common bathroom is equipped with a shower, toilet, 2 sink vanity and cabinets for storage. The
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024
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 07/30/2024 05:47 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: YOUR HOME ASSISTED LIVING
FACILITY NUMBER: 197609778

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above per tour of the bedrooms, LPA observed that the hospital bed in bedroom #2, used by Resident #4, who is not on hospice, was equipped with 2 half rails to create a full bed rail.
POC Due Date: 08/06/2024
Plan of Correction
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Licensee will ensure that residents beds are not equipped with full bedrails unless they are included in the residents hospice care plan or if a doctors order has been and an exception has been obtained from the Department for their use. Licensee will remove one of the 1/2 bed rails or submit a request to the Department for an exception for the use of a full bed rail by 8/6/24. *************one of the half bed rails was removed during this visit. Corrected at the time of the visit*****
Type B
Section Cited
CCR
87633(b)(6)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (6) Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee's responsibilities for implementation of the hospice care plan.

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 per information provided, staff has been provided with training for the 2 residents who are currently on hospice but there is no documentation of what training was provided and which staff were trained and who did the training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/06/2024
Plan of Correction
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Licensee will ensure that staff are provided with the training needed for the care of residents on hospice, per their care plan and the training is documented in writing prior to providing hospice care. Licensee with obtain the training provided to the staff for the care of Resident #2 and Resident #4 and maintain it with the hospice care plan by 8/6/24
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: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024
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: YOUR HOME ASSISTED LIVING
FACILITY NUMBER: 197609778
VISIT DATE: 07/30/2024
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  • water temperature was tested in the shower and it read 107 degrees Fahrenheit. The water temperature for the sink was tested and it read 88.2 degrees Fahrenheit.
  • the staff bathroom located by the front door was observed with a shower stall, a large bath tub and a sink.
  • Bedroom #3 was observed with 2 hospital beds with 1/2 bed rails, 2 night stands, 2 lamps, a shared closet, 1 chair and no dresser at the request of the resident. 2 extra dressers were observed stored in the garage.
  • the staff bedroom/office located in the back of the facility was furnished with a desk, chair and a bed for staff use.
  • extra bed linens were observed in the linen closet
  • the facility has current liability insurance that meets Title 22 requirements
  • the hardwired smoke detectors and combination smoke/carbon monoxide detectors were tested and were operational.
  • the first aid kit was reviewed and a tweezer, scissors was observed. The facility has a separate thermometer. Also observed was a first aid manual.
  • the back of the house has a ramp that goes down to the covered patio and it was furnished with chairs and a table for outside activities. The backyard is enclosed with a gate along the side of the facility.
  • The common areas, bedrooms, backyard, front yard and the side of the facility looked clean and well maintained.
  • the trash cans located in the front 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, Appeals Rights were discussed and a copy was provided.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 07/30/2024 05:47 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: YOUR HOME ASSISTED LIVING
FACILITY NUMBER: 197609778

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
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
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Based on observation, the licensee did not comply with the section cited above per the water temperature taken in the sink of the common bathroom designated for the residents. The water temperature in the shower read 107 degrees and the water temperature in the sink used for handwashing read 88.20 degrees Fahrenheit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2024
Plan of Correction
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 Licensee will adjust the thermostat for the water heater to allow the water temperature for the wate going to the sink to attain the required Title 22 temperature of 105 - 120 degrees Fahrenheit by. Provide evidence that the water temperature has been corrected by 7/31/24
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4