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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609793
Report Date: 11/02/2021
Date Signed: 11/02/2021 10:44:09 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 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:
11/02/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Ani Gabrielian, AdministratorTIME COMPLETED:
10:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Salia Walker conducted an announced Case Management-Deficiencies visit today to follow up on deficiencies cited during a conducted annual visit. The LPA met with Ani Gabrielian at 10:23 a.m. and explained the reason for the visit. At 8:51 a.m., the LPA conducted a physical plant tour.

On 09/14/2021, LPA Walker conducted a required annual visit where deficiencies were cited. At 12:06 p.m., the LPA conducted a physical plant tour of the garage to ensure there were no residents living in the garage and identified that there were two (2) tenants living in the facility’s garage which was converted and included a kitchenette, bedroom, and private bathroom. The LPA confirmed that these two (2) individuals were not associated to this facility nor had a criminal background clearance. Between 11:35 a.m. and 02:45 p.m., on 9/14/2021, the LPA reviewed resident files with the administrator. Upon review of resident files, and resident confirmation, it was observed that Resident #1 (R1), and Resident #2 (R2) were both bedridden. The facility is cleared through Fire Safety to have five (5) non-ambulatory resident and one (1) bedridden resident. The facility was not cleared to have both R1 and R2 reside in the facility, and therefore was required to find a proper relocation for either R1 or R2.
During today’s visit, the LPA confirmed that the two (2) tenants that were residing in the facility garage are no longer residing at this location based on the observation of a vacant garage with no belongings observed to be left behind. The LPA also confirmed that one (1) out of two (2) bedridden residents were relocated. The administrator confirmed R1 has been relocated to: ‘Bassett Residential Care’. As a result, there is only one (1) bedridden resident (R2) residing room #3 which is approved for (1) bedridden resident. At 9:00 a.m., the LPA observed Pests on the bedroom closet door located in the facility garage.

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. 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: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
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 3
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: 11/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/02/2021
Section Cited

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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:
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Based on 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.
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Type A
11/02/2021
Section Cited

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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:
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Based on observation, the licensee did not comply with the section cited above, as the facility's garage was converted without permit from Building and Safety clearing for habitation, which poses an immediate 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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 11/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/02/2021
Section Cited

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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:
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Based on review of resident files confirmation with the Administrator, the licensee did not comply with the section cited above, as R1, and R2 were both bedridden and the facility is only cleared for one (1) bedridden resident, which poses an immediate safety risk to resident in care.
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Type B
11/02/2021
Section Cited

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87303(a) Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
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Based on observation, the licensee did not comply with the section cited above, as the LPA observed Pests on the bedroom closet door located in the facility garage, which poses a potential health and safety risk to resident 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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3