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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609788
Report Date: 08/29/2024
Date Signed: 08/30/2024 09:09:27 PM

Document Has Been Signed on 08/30/2024 09:09 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:NORTHRIDGE GARDENS BOARD & CARE, INC.FACILITY NUMBER:
197609788
ADMINISTRATOR/
DIRECTOR:		KHACHATUROVA, GAYANEFACILITY TYPE:
740
ADDRESS:18915 LIEDAN STTELEPHONE:
(818) 917-5104
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 6CENSUS: 4DATE:
08/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Ani TigranyanTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with staff and explained the reason for the visit. Administrator, Gayane Khachaturova could not attend the annual inspection for the day due to an illness. LPA was informed that the facility was sold on or around June 2024. Records Review indicated that there are no written notification was sent to CCL and residents responsible party regarding the facility sale.

At approximately 10:05 am, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms and carbon monoxide detectors are dual. Smoke alarms are hardwired and interconnected. The fire extinguisher is located in the kitchen with purchase date 05/28/2024.

Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in a closet by the kitchen.
Bedrooms: There were (5) bedrooms designated for residents' use. All five rooms are for private use. All rooms were properly furnished with appropriate beddings and linens with sufficient lighting. There is also a sufficient supply of linen and towels stored in the linen closet.
Bathrooms: There are two (2) bathrooms designated for residents' use. One (1) bathroom is attached to a private room. All the bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 114.6 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathroom during the inspection.
Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit.
Garage/Storage Room: Garage is kept locked. The laundry area is located in the garage, which is inaccessible to residents.
Temperature: of facility wall thermostat was set at 74.0°F and observed to be within the required range.
(Conintune on 809C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: NORTHRIDGE GARDENS BOARD & CARE, INC.
FACILITY NUMBER: 197609788
VISIT DATE: 08/29/2024
NARRATIVE
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Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. The outdoor area was free of hazards.

Resident Files: LPA conducted a file review of resident records to ensure compliance with licensing forms. LPA observed that there's no physical file available for R1.

Staff Files: LPA also conducted a file review of staff records and observed that S1, S2, S3, and S4 have no physical files available. S1 has no fingerprint clearance and is not associated with the facility.

Medications: LPA could not complete an accurate medication count due to incomplete medication forms for all the residents.

Exit interview conducted, civil penalties and other citations issued, appeal rights given and a copy of this report delivered.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 08/30/2024 09:09 PM - It Cannot Be Edited


Created By: Mariana Agban On 08/29/2024 at 03:33 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: NORTHRIDGE GARDENS BOARD & CARE, INC.
FACILITY NUMBER: 197609788

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1524.1(a)(1)
The licensee shall provide written notice to the department and to each resident or client or his or her legal representative of the licensee's intent to sell the facility at least 60 days prior to the transfer of property or business, or at the time that a bona fide offer is made, whichever period is longer.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews the licensee did not comply with the section cited above. The Licensee sold the facility in or around June 2024 without providing a written notification to CCL or residents responsible party. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2024
Plan of Correction
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Administrator will submit a written notification to CCL and residents responsible party by the POC date
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:Eva Miller
LICENSING EVALUATOR NAME:Mariana Agban
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024


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Document Has Been Signed on 08/30/2024 09:09 PM - It Cannot Be Edited


Created By: Mariana Agban On 08/29/2024 at 03:41 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: NORTHRIDGE GARDENS BOARD & CARE, INC.
FACILITY NUMBER: 197609788

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. LPA could not complete an accurate medication count due to incomplete medication forms for all the residents. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/12/2024
Plan of Correction
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Administrator agreed to submit completed medication forms by the POC date
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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:Eva Miller
LICENSING EVALUATOR NAME:Mariana Agban
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024


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Page: 4 of 7
Document Has Been Signed on 08/30/2024 09:09 PM - It Cannot Be Edited


Created By: Mariana Agban On 08/29/2024 at 03:41 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: NORTHRIDGE GARDENS BOARD & CARE, INC.
FACILITY NUMBER: 197609788

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Eva Miller
LICENSING EVALUATOR NAME:Mariana Agban
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024


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Document Has Been Signed on 08/30/2024 09:09 PM - It Cannot Be Edited


Created By: Mariana Agban On 08/29/2024 at 03:52 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: NORTHRIDGE GARDENS BOARD & CARE, INC.
FACILITY NUMBER: 197609788

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. S1 has no finger print clearance and not associate it with the facility. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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S1 is removed immediately from the facility. Fingerprint clearance and association documents will be submitted by the POC date and a $500 civil penalty is assessed
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:Eva Miller
LICENSING EVALUATOR NAME:Mariana Agban
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024


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Document Has Been Signed on 08/30/2024 09:09 PM - It Cannot Be Edited


Created By: Mariana Agban On 08/29/2024 at 04:11 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: NORTHRIDGE GARDENS BOARD & CARE, INC.
FACILITY NUMBER: 197609788

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(e)


All personnel records shall be maintained at the facility site. 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. S1,S2, S3 and S4 have no physical file available which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/12/2024
Plan of Correction
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Administrator agreed to provide copies of staff folders by the POC date
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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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:Eva Miller
LICENSING EVALUATOR NAME:Mariana Agban
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024


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