197609793-9-20-2021-29-AS-SWAR-C72PR7-20210920113217

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609793
Report Date: 09/20/2021
Date Signed: 09/20/2021 11:33:47 AM

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 LIVING		FACILITY NUMBER:	197609793
ADMINISTRATOR:	ANI A. GABRIELIAN		FACILITY TYPE:	740
ADDRESS:	6608 SAINT CLAIR AVE		TELEPHONE:	(818) 983-2224
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY:	6	CENSUS: 6	DATE:	09/20/2021
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	09:32 AM
MET WITH:	Ovsanna Norentsayan, Designee		TIME COMPLETED:	11:35 AM

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) Salia Walker conducted an unannounced Plan of Correction (POC) visit to follow up regarding the plan of corrections that were due by 09/16/21. The LPA met with Designee Ovsanna Norentsayan and explained the reason for the visit. At 10:01 a.m., LPA Walker conducted a physical plant tour. On 09/14/2021, LPA Walker conducted a required annual visit where the following deficiencies were cited, and civil penalties were issued. Between 11:35 a.m. and 02:45 p.m., LPA Walker conducted a review of resident files. Upon review of resident files resident and resident confirmation with the Administrator, it was observed that Resident #1 (R1), and Resident #2 (R2) are both bedridden. The facility is cleared through Fire Safety to have five (5) non-ambulatory clients and one (1) bedridden client. The Administrator had agreed to submit an updated LIC200 and facility sketch to CCL by 09/16/21. As well as, request a fire clearance for two (2) bedridden clients from Fire Safety. The administrator was advised that Failure to obtain the clearance would result in the resident’s relocation. Based on the physical plant tour conducted by the LPA. The Licensee has failed to meet the Plan of correction. 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. 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. Continue on LIC-809C..

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021

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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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: 09/20/2021

NARRATIVE

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The Administrator stated she was not able to reach the Licensee representative/ property owner.
The Administrator had agreed to submit documentation for T1, and T2 background clearance by 09/16/21. Based on the physical plant tour conducted by the LPA. The Licensee has failed to meet the Plan of correction.

Although the administrator submitted statements on 09/17/2021, in attempt to clear the above citations. The statement submitted for T1 and T2 being relocated by no later than 10/01/21 was insufficient as tenants need to have proper fingerprint/background check clearance in order to resided on the facility premises. The statement submitted requesting a temporary waiver for R2 due to her ‘decline in condition’ is not granted due to facility needing a Fire Clearance from the Fire Department. Therefore, these submitted statements in attempt to clear the POCs are insufficient.

During today’s visit, the LPA informed the Administrator and the Licensee/Property Owner via telephone that due to it appearing T1 and T2 are still residing on the property without background clearance, civil penalties will continue to accrue at $100 a day until the citation is sufficiently corrected. The LPA also, informed the administrator that due to it appearing R2 is still residing on the property without proper Fire Safety clearance to have two (2) bedridden clients, a reassessment of civil penalties will continue to accrue at $100 per day until the citation is sufficiently corrected.

Pursuant to Title 22 Division 6 Chapter 8 of the California Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Civil Penalties assessed.
Exit interview conducted, today's reports and appeal rights were reviewed and issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021

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
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: 09/20/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/16/2021 Section Cited	1 2 3 4 5 6 7	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:
	8 9 10 11 12 13 14	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 submitting proper background clearance to CCLD, which poses an immediate safety risk to residents in care.	8 9 10 11 12 13 14
Type A 09/16/2021 Section Cited	1 2 3 4 5 6 7	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:
	8 9 10 11 12 13 14	Based on review of resident files confirmation with the Administrator, the licensee did not comply with the section cited above, as resident #2 (R2) is bedridden(See LIC858). Facility does not have Fire Clearance for two (2) bedridden residents, which poses an immediate safety risk to resident in care.	8 9 10 11 12 13 14

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: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021

LIC809 (FAS) - (06/04)

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