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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609829
Report Date: 07/17/2023
Date Signed: 07/17/2023 04:55:25 PM


Document Has Been Signed on 07/17/2023 04:55 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:ARARAT BOARD AND CAREFACILITY NUMBER:
197609829
ADMINISTRATOR:SARGSYAN, KARINEFACILITY TYPE:
740
ADDRESS:6614 TEESDALE AVETELEPHONE:
(818) 624-4180
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY:6CENSUS: 6DATE:
07/17/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Mariam Panadhzyan, LicenseeTIME COMPLETED:
05:10 PM
NARRATIVE
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Licensing Program Analyst(LPA) Christine Yee conducted an unannounced case management visit due to the deficiencies noted during a visit to the facility today.

Per review of 3 out of 6 residents' facility file, Resident files are incomplete. Resident #1 does not have an Admissions Agreement, Identification and Emergency Information(LIC601), Resident #2 does no have Appraisal/Needs and service. Resident #3's hospitalization on 5/20/23 was not reported to licensing

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8


Exit interview was conducted, Appeals Rights discussed and a copy was provided.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2023
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


Document Has Been Signed on 07/17/2023 04:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: ARARAT BOARD AND CARE
FACILITY NUMBER: 197609829

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/18/2023
Section Cited
CCR
87211(a)(1)(A-D)

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(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified
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Licensee will complete an LIC624-Special Incident report for the hospitalization of Resident #1 on 5/20/23 and submit it to licensing by 7/18/23
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 (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. Licensee did not report Resident #1's hospitalization on 5/202/3
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Type B
07/24/2023
Section Cited
CCR87507(a)(1-2)

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a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. 1) The text of the admission agreement, including any attachments and modifications, shall be
(A) Printed in black type of not less than 12-
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The Licensee will ensure that all residents have a completed and signed copy of an Admission Agreement on file for every resident. LIcensee will review all residents files and complete an Admission agreement. Provide evidence that all residents have a Signed Admission Agreement by 7/24/23
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-point type size, on plain white paper. The print shall appear on one side of the paper only.(B) Written in clear, understandable, coherent, and unambiguous language, using words with common and everyday meanings, and shall be appropriately divided with each section appropriately titled.
Resident #1 does not have an admission agreenmer
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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: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 07/17/2023 04:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: ARARAT BOARD AND CARE
FACILITY NUMBER: 197609829

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/24/2023
Section Cited
CCR
87506(b)(1-17)

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Resident Record- Each resident’s record shall contain at least the following information:(1) Resident's legal name and preferred name, as indicated by the resident.
(2) Social Security number.
(3) Gender identity and preferred pronoun, as indicated by the resident.
(4) Dates of admission and discharge.
(5) Last known address..
(6) Birthdate.
(7) Religious preference, if any, and name and address of clergyman or religious advisor, if any
(8) Names, address, and telephone numbers of the resident’s representative,
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Licensee will review all resident files to ensure that their file includes all the required documents. Provide evidence that the file review has been completed and that all files are availale for review by 7/24/23
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as defined in Section 87101(r), to be notified in case of accident, death, or other emergency.
(9) Name, address and telephone number of physician and dentist to be called in an emergency.
(10) Reports of the medical assessment specified in Section 87458, Medical Assessment, and of any special problems or precautions.
(11) The documentation required by Section 87611 for residents with an allowable health condition.
(12) Ambulatory status.
(13) Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or needed services.
(14) Current centrally stored medications as specified in Section 87465, Incidental Medical and Dental Care Services.
(15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.
(16) Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables.
(17) Documents and information required by the following:
(A) Section 87457, Pre-Admission Appraisal;
(B) Section 87459, Functional Capabilities;
(C) Section 87461, Mental Condition;
(D) Section 87462, Social Factors;
(E) Section 87463, Reappraisals; and
(F) Section 87505, Documentation and Support.
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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: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2023
LIC809 (FAS) - (06/04)
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