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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609793
Report Date: 09/14/2021
Date Signed: 09/14/2021 06:38:29 PM

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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:SAINT CLAIR ASSISTED LIVINGFACILITY NUMBER:
197609793
ADMINISTRATOR:ANI A. GABRIELIANFACILITY TYPE:
740
ADDRESS:6608 SAINT CLAIR AVETELEPHONE:
(818) 983-2224
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY:6CENSUS: 6DATE:
09/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:09 AM
MET WITH:Ovsanna Norentsayan, DesigneeTIME COMPLETED:
06:40 PM
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Licensing Program Analyst (LPA) Salia Walker arrived at the facility unannounced to conduct a required Annual visit at 11:09 a.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Ani Gabrielian at 11:57 a.m., and explained the reason for the visit.

At 11:10 a.m., the LPA observed the gate entrance in front of the facility to be locked from both sides, needing a key to unlock the gate from inside or outside the facility property. Staff #1 (S1) needed a key to unlock the gate in order to allow the LPA entry onto the facility property. This is a fire clearance violation. The LPA informed the administrator of this, and they stated that they would remove the deadbolt mechanism on the gate to ensure that it was single latch only. The LPA observed the Administrator removed the deadbolt mechanism from the gate, at 05:53 p.m.
The LPA toured the physical plant areas inside and outside at 11:40 a.m., to ensure there are no health and safety hazards.
BEDROOMS: The LPA observed the resident bedrooms which were furnished with clean linens, appropriate furnishings, and sufficient lighting.
RESTROOMS: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap, paper products, and hand-washing signs in each restroom.
Between 11:44 a.m. to 11:51 a.m., hot water temperatures measured between 125.5 and 130 degrees Fahrenheit in the common, private bathroom(s), and the kitchen. The LPA advised the Administrator the hot water temperature is to attain a temperature of not less than 105 degrees Fahrenheit (41 degree C) and not more than 120 degrees Fahrenheit (49 degree C). The Administrator was advised this poses an immediate health and safety risk to residents in care.

Continued on LIC 809C..

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SAINT CLAIR ASSISTED LIVING
FACILITY NUMBER: 197609793
VISIT DATE: 09/14/2021
NARRATIVE
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KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 11:42 a.m., the LPA observed culinary knives were accessible in the kitchen, which poses an immediate health and safety risk to residents in care. The LPA advised the Administrator that all sharps including knives must remain locked and secured at all times while caring for persons with dementia.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed required postings in the hallway. One fire extinguisher was observed to be fully charged.

BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted.

GARAGE: The garage is detached from the facility located within approximately two feet from the facility. At 12:06 p.m., the LPA identified there were two (2) tenants living in the facility’s Garage. Tenant #1 (T1) stated that they were renting the garage, and that they live there. The Administrator and the LPA conducted a tour of the converted garage, which included a kitchenette, bedroom, and private bathroom, to ensure there were no residents living in the garage. Tenant #2 (T2) was in the garage converted bedroom. The LPA confirmed that these individuals were not associated to this facility nor background cleared. No further information was provided by T1 or T2. The LPA advised the Administrator that this is a Fire Clearance Violation and a criminal record clearance violation, and the garage is not cleared for habitation. The LPA inquired whether the facility has a permit with Building and Safety to have the garage converted. The Administrator stated she had no knowledge of whether there was a permit obtained, and had no knowledge of tenants residing in the garage. The Administrator stated she would contact the Licensee representative/ property owner to obtain additional information. The Administrator stated she was not able to reach the Licensee representative/ property owner.

Continued on LIC 809C..

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
LIC809 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SAINT CLAIR ASSISTED LIVING
FACILITY NUMBER: 197609793
VISIT DATE: 09/14/2021
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Record Review: The LPA reviewed files for residents and staff regularly scheduled at the facility with the Administrator between 11:35 a.m. and 02:45 p.m. Resident files were reviewed for admission agreements, medical assessments, appraisals, consent forms and medication records. Upon review of resident files resident and resident confirmation and with the Administrator, it was observed that Resident #1 (R1), and Resident #2 (R2) are both bedridden. The LPA advised the administrator that R2 needs an updated physicians report and appraisal. The facility is cleared through Fire Safety to have five (5) non-ambulatory clients and one (1) bedridden client. The LPA also advised the Administrator that this is an addition to the fire clearance violation due to the facility’s acceptance and retention limitation Tittle 22 Regulation section H&S CODE 1569.72; 87202 Fire Clearance; 87455(c)(4)(g) Acceptance and Retention Limitations; 87208 Plan of Operation: Staff files had the sufficient training documentation, criminal record clearance and association to this facility.


INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. The LPA did not observe an adequate supply of Personal Protection Equipment (PPE). The LPA advised the administrator that the facility is able to obtain additional supplies through CDSS RO, and other agencies to ensure they have adequate supply of Personal Protection Equipment (PPE). The facility’s cleaning protocol is sufficient. If needed, the facility has a plan in place to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time and the LPA reviewed facility’s policies and procedures as it pertains to infection control.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Civil penalties issued.
Exit interview conducted. A copy of the report and appeal rights was provided.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
LIC809 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SAINT CLAIR ASSISTED LIVING
FACILITY NUMBER: 197609793
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
87705(f)(1) Care of Persons with Dementia: (f)The following shall be stored inaccessible to residents with dementia: (1)Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

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, as culinary knives were accessible during physical plant tour, which poses an immediate health and safety risk to residents in care.
POC Due Date: 09/14/2021
Plan of Correction
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The Administrator agreed to do the following:
1. The staff secured the sharps/ culinary knives upon observation. Plan of correction met.
Type A
Section Cited
CCR
87303(e)(2)(e)
87303(e)(2)(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 observations, the licensee failed to ensure hot water temperature measured within 105 to 120 degrees F in resident rooms which poses an immediate health, and safety risk to residents in care.
POC Due Date: 09/21/2021
Plan of Correction
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The Licensee has agreed to do the following:
1. Submit proof by photos, and receipt of temperature adjustment.
2. Submit a hot water temperature log for five (5) days to maintain water temperature between n 105 - 120 degrees F.
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 PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2021
LIC809 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SAINT CLAIR ASSISTED LIVING
FACILITY NUMBER: 197609793
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
87355(e)(2) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to... in a licensed facility: (2) Request a transfer of a criminal record clearance…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and observations, the licensee did not comply with the section cited above, as two individuals (T1, T2) have been living in the facility’s garage without a permit with Building and Safety to have the garage converted and a background clearance, which poses an immediate safety risk to residents in care.
POC Due Date: 09/16/2021
Plan of Correction
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The Licensee has agreed to do the following:
1. Submit documentation for T1, and T2 to be associated with the facility with background clearance.
2. Submit proof of Building and Safety Permit allowing habitation and conversion of the facility’s garage.
Zero tolerance violation; immediate civil penalty assessed of $1000
Type A
Section Cited
CCR
87203
87203 Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

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, as the entrance gate was locked from the inside of the property to the facility grounds which poses an immediate health and safety risk to residents in care.
POC Due Date: 09/14/2021
Plan of Correction
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During today's visit, the Licensee removed the deadbolt mechanism leaving only the single-latch lock which allows for locking from the outside but can egress safely from the inside. Plan of Correction met.

Fire clearance violation; immediate civil penalty assessed of $500
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 PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2021
LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SAINT CLAIR ASSISTED LIVING
FACILITY NUMBER: 197609793
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87455(c)(4)(g)
H&S CODE 1569.72; 87202 Fire Clearance; 87455(c)(4)(g) Acceptance and Retention Limitations; 87208 Plan of Operation:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of resident files resident and resident confirmation and with the Administrator, the licensee did not comply with the section cited above, as resident #2 (R2) is bedridden (See LIC858), and unable to reposition self in bed w/o assistance and cannot independently transfer to and from bed. Facility does not have a bedridden clearance for two (2) clients in order to retain the resident..
POC Due Date: 09/20/2021
Plan of Correction
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The Licensee has agreed to do the following:
1. Submit an updated LIC200 and facility sketch to CCL by 09/16/21.
2. Request a fire clearance for two (2) bedridden clients. Failure to obtain the clearance will result in the resident’s relocation.
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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2021
LIC809 (FAS) - (06/04)
Page: 6 of 6