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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609785
Report Date: 09/14/2022
Date Signed: 09/14/2022 04:58:40 PM

Document Has Been Signed on 09/14/2022 04:58 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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:EATON CANYON VILLAS IFACILITY NUMBER:
197609785
ADMINISTRATOR:GARIBYAN, ARMONDFACILITY TYPE:
740
ADDRESS:2518 GANESHA AVETELEPHONE:
(818) 429-0070
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY: 6CENSUS: 6DATE:
09/14/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:37 PM
MET WITH:Aura Amaya-Lopez, ManagerTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced Case Management visit in conjunction with complaint control #31-AS-20211123140157. The purpose of the Case Management visit is to issue a citation for a deficiency observed during the course of the complaint investigation that is not directly related to the complaint.

During the investigation, LPA noted the following:

Staff were not able to provide a resident's record upon request. LPA arrived at the facility at 1:00pm. Designated facility representative was not present. LPA waited for 90 minutes for representative to arrive. LPA then asked other staff if they could provide the records and was told that they could not. LPA spoke on the phone to the representative and was told they do not have access to the files since the resident is no longer present at the facility. In addition, LPA was told that licensee is also not available since they are on vacation.

Pursuant to the California Code of Regulations, Title 22, the following deficiency was observed and cited during the visit. Exit interview conducted, a copy of the report, citations, and appeal rights were issued.


SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2022
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 09/14/2022 04:58 PM - It Cannot Be Edited


Created By: Rosaura Valenzuela On 09/14/2022 at 03:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: EATON CANYON VILLAS I
FACILITY NUMBER: 197609785

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/21/2022
Section Cited

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87506 Resident Records-(d) All resident records shall be available to the licensing agency to inspect, audit, and copy for upon demand during normal business hours...

This requirement was not met as evidenced by:
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Based on interview and observation, Licensee did not ensure to have a resident's records readily available to LPA upon request.

This 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:Naira Margaryan
LICENSING EVALUATOR NAME:Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2022


LIC809 (FAS) - (06/04)
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