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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197609829
Report Date:
09/25/2023
Date Signed:
09/26/2023 12:53:01 PM
Document Has Been Signed on
09/26/2023 12:53 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 N.ASC
,
21731 VENTURA BLVD. #250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
ARARAT BOARD AND CARE
FACILITY NUMBER:
197609829
ADMINISTRATOR:
SARGSYAN, KARINE
FACILITY TYPE:
740
ADDRESS:
6614 TEESDALE AVE
TELEPHONE:
(818) 624-4180
CITY:
NORTH HOLLYWOOD
STATE:
CA
ZIP CODE:
91606
CAPACITY:
6
CENSUS:
6
DATE:
09/25/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
10:14 AM
MET WITH:
Mariam Panadzhyan, Licensee
TIME COMPLETED:
07:50 PM
NARRATIVE
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LIcensing Program Analyst (LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool and met with Mariam Panadzhyan, Licensee. The reason for today's visit was explained.
The facility is a single storey family home consisting of a living room, dining room, kitchen, 5 bedrooms and 3-1/2 bathrooms. Per information provided on today's visit, the Licensee extended the back wall of the home by adding a full bathroom to the staff room and a 1-1/2 bathroom for visitor use about 3 years ago. The Department was not notified of the addition. Per Licensee, no permits were obtained for the extension. The previously attached garage located in front of the facility, was converted to an alternate dwelling unit prior to licensure of the facility and has its own address and access. Also located in the back is a separate building used for food storage and the laundry room. The facility is fire cleared for 5 NON-AMBULATORY and 1 BEDRIDDEN resident. Bedroom #4 is designated for bedridden use.
The following was observed on today's visit:
The dining room, living room and kitchen all have the appropriate furniture and equipment.
Sufficient perishable and non-perishable foods were observed in the kitchen and in the back storage building.
Located in the kitchen is the first fire extinguisher purchased on 7/29/23
Bedroom #1 is a shared room and has 2 beds, 1 chair, 1 night stand, 2 lamps, 2 dressers. The exit door is not equipped with a auditory device. Located in the bedroom is the second fire extinguisher
Bedroom #2 has 2 beds, 1 lamp, 1 chair, 1 night stand and no dresser.
Bedroom #3 is a shared room and has 2 beds, 3 night stands, 2 chairs, 2 lamps, 2 built in closets and
SUPERVISOR'S NAME:
Kristin Heffernan
TELEPHONE:
(818) 596-4493
LICENSING EVALUATOR NAME:
Christine Yee
TELEPHONE:
(747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE:
09/25/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/25/2023
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
WOODLAND HILLS N.ASC
,
21731 VENTURA BLVD. #250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
ARARAT BOARD AND CARE
FACILITY NUMBER:
197609829
VISIT DATE:
09/25/2023
NARRATIVE
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1 dresser. Bed by the back wall had no blankets or flat sheets.
Bedroom #4, designated for bedridden use has 2 beds, 2 portable closets, 1 chair, 2 night stands, 1
lamp, 1 dresser. The back door opens out on to a ramp. Licensee needs to relocate the night stand that is partially blocking the door. No auditory device was observed on the door. No blankets or flat sheets were observed on the bed closest to the bedroom door.
A bed must be removed from bedroom #2 and bedroom #4 as this will take the facility over capacity.
located inside bedroom #4 is a private bathroom with a shower stall, a bath tub, a sink. No grab bars or non-skid mats were observed in the tub or the shower stall. Per the Licensee, the bathroom is not used. Water temperature was tested and read 118.5 degrees Fahrenheit.
The common bathroom is equipped with a shower, shower chair, grab bars, non-skid mat. Water temperature was tested and read 118.6 degrees Fahrenheit.
The staff room is an office with a sofa. The medications and knives are stored in a locked filing cabinet. Located inside the office is a private bathroom that was added without a permit
Located by the back exit door is the visitor's bathroom that was added without a permit.
Per tour of the front yard, it was observed to be clean. Trash cans were observed tightly sealed. Seating was also observed by the front door.
Per tour of the back yard, a table with 5 chairs were observed set up under the roof of the back building. The back yard was clean.
The smoke/carbon monoxide combination detectors were tested and were operational.
the first aid kit was reviewed and met Title 22 requirements.
no first aid manual was observed or could be provided for verification.
per review of staff records, Gayane Ademyan does not have first aid training and LPA was not able to verify current first aid training for Karine Sargsyan.
Astkhik Kebabjian, new staff who started today, does not have a criminal record clearance.
Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Any citations not issued on today's visit will be cited on a return visit. IMMEDIATE CIVIL PENALTIES WERE ASSESSED.
Exit Interview was conducted, Appeals Rights discussed and a copy was given.
SUPERVISOR'S NAME:
Kristin Heffernan
TELEPHONE:
(818) 596-4493
LICENSING EVALUATOR NAME:
Christine Yee
TELEPHONE:
(747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE:
09/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/25/2023
LIC809
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Document Has Been Signed on
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- 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 N.ASC
,
21731 VENTURA BLVD. #250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
ARARAT BOARD AND CARE
FACILITY NUMBER:
197609829
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/25/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(f)(2)
Maintenance and Operation
(f) Solid waste shall be stored and disposed of as follows: (2) Syringes and needles are disposed of in accordance with the California Code of Regulations, Title 8, Section 5193 concerning bloodborne pathogens.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on interview, the licensee did not comply with the section cited above as per information provided, the used needles for Resident #5 are tossed in the trash can which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
09/27/2023
Plan of Correction
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The Licensee will contact the pharmacy and come up with a plan to properly and safely dispose of all needles used in the facility by 9/27/23
Type A
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
Prior to construction or alterations, all facilities shall obtain a building permit.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above per review of facility sketch and tour of the physical plant that there were 2 additional bathrooms added and without notification to the Department and without permits which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
10/03/2023
Plan of Correction
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2
3
4
The Licensee will contact the city to obtain permits or instructions as to how the addition can be brought to code and provide the Department evidence that the addition is now up to code or has been approved by the city by 10/03/23
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:
Kristin Heffernan
TELEPHONE:
(818) 596-4493
LICENSING EVALUATOR NAME:
Christine Yee
TELEPHONE:
(747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE:
09/25/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/25/2023
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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
WOODLAND HILLS N.ASC
,
21731 VENTURA BLVD. #250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
ARARAT BOARD AND CARE
FACILITY NUMBER:
197609829
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/25/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(5)
Incidental Medical and Dental Care Services
(5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited to the following:
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 per information received, the Licensee is administering insulin injections to Resident #5 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
09/27/2023
Plan of Correction
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Licensee will provide the Department with a plan by 9/27/23 as to how the facility will come into compliance with how the resident in care receives the prescribed insulin without staff having to administer injectable medications by 9/27/23
Type A
Section Cited
CCR
87465(h)(1)(C)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (C) Because of potential dangers related to the medication itself, or due to physical arrangements in the facility and the condition or the habits of other persons in the facility, the medications are determined by either a physician, the administrator, or Department to be a safety hazard to others.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observations, the licensee did not comply with the section cited above per tour of the facility, it was observed that the Licensee stored prescribed insulin, Lantus in the butter compartment of the refrigerator without securing the medication from other residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
09/27/2023
Plan of Correction
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4
The licensee will provide the Department with a plan as to how medications that need to be refrigerated will be made inaccessible to the other residents, especially those with dementia by 9/27/23
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:
Kristin Heffernan
TELEPHONE:
(818) 596-4493
LICENSING EVALUATOR NAME:
Christine Yee
TELEPHONE:
(747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE:
09/25/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/25/2023
LIC809
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Page:
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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
WOODLAND HILLS N.ASC
,
21731 VENTURA BLVD. #250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
ARARAT BOARD AND CARE
FACILITY NUMBER:
197609829
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/25/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above per tour of the facility, LPA observed that the file cabinet used to store the medications were left unlock and in an unlocked office while staff were assisting other residents and while they were outside the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
09/27/2023
Plan of Correction
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3
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Licensee will ensure that all centrally stored medications are made inaccessible to residents in care at all times. The licensee locked the cabinet and office door during the visit
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
1
2
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:
Kristin Heffernan
TELEPHONE:
(818) 596-4493
LICENSING EVALUATOR NAME:
Christine Yee
TELEPHONE:
(747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE:
09/25/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/25/2023
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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
WOODLAND HILLS N.ASC
,
21731 VENTURA BLVD. #250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
ARARAT BOARD AND CARE
FACILITY NUMBER:
197609829
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/25/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(4)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (4) Grab bars shall be maintained for each toilet, bathtub and shower used by residents.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above per tour of all 3-1/2 bathrooms inspected, the private bathroom located inside Bedroom #4 did not have grab bars in the bath tub or in the shower stall which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/03/2023
Plan of Correction
1
2
3
4
Licensee will ensure that all bathrooms available for resident use are equipped with grab bars. Provide evidence that grab bars have been installed for resident use by 10/3/23
Type B
Section Cited
CCR
87307(a)(3)(B)
Personal Accommodations and Services
(B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above per tour of the 4 resident bedrooms, Bedrooms #2 and Bedroom #3 do not have a chest of drawers that meet Title 22 requirements of 8 cubic feet for 2 of the residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/03/2023
Plan of Correction
1
2
3
4
Licensee will ensure that all residents have a chest of drawers meeting Title 22 requirements. LIcensee will provide a chest of drawers for resident in Bedroom #2 and Bedroom #3 by 10/3/23
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:
Kristin Heffernan
TELEPHONE:
(818) 596-4493
LICENSING EVALUATOR NAME:
Christine Yee
TELEPHONE:
(747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE:
09/25/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/25/2023
LIC809
(FAS) - (06/04)
Page:
6
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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
WOODLAND HILLS N.ASC
,
21731 VENTURA BLVD. #250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
ARARAT BOARD AND CARE
FACILITY NUMBER:
197609829
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/25/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(3)(C)
Personal Accommodations and Services
(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above per tour of the residents' bedrooms, residents beds had a mattress cover, fitted sheet and a comforter. Beds did not have a flat sheet, blanket/comforter. An extra fitted sheet and a flat sheet were stored in the bottom of the dresser drawers. The quantity does not allow for weekly changing or as needed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/03/2023
Plan of Correction
1
2
3
4
Licensee will purchase additional bed linens-fitted sheets, flat sheets, pillow cases, blankets and comforters in quantities that will allow the bed linens to be changed weekly or as needed
Type B
Section Cited
CCR
87468(c)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above per inspection of posters on the facility wall, there were no personal rights posted in the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/03/2023
Plan of Correction
1
2
3
4
Licensee will ensure that posters advising resident in care of their personal rights and complaint information by 10/3/23
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:
Kristin Heffernan
TELEPHONE:
(818) 596-4493
LICENSING EVALUATOR NAME:
Christine Yee
TELEPHONE:
(747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE:
09/25/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/25/2023
LIC809
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Page:
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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
WOODLAND HILLS N.ASC
,
21731 VENTURA BLVD. #250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
ARARAT BOARD AND CARE
FACILITY NUMBER:
197609829
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/25/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(1)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities shall be posted as applicable to the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above per review of posted posters by kitchen, there was no posters advising the residents in care of Additional Personal Rights of Residents in Privately Operated Facilities which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/03/2023
Plan of Correction
1
2
3
4
Licensee will post information regarding Additional Personal Rights of Residents in Privately Operated Facilities in a conspicuous area for viewing by residents in care and families.
Type B
Section Cited
CCR
87468(c)(2)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above per review of facility posting by the kitchen that the facility does not provide information on the appropriated reporting agency in case of a complaint, with contact information which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/03/2023
Plan of Correction
1
2
3
4
Licensee will ensure that information for the Department and contact information is posted.
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:
Kristin Heffernan
TELEPHONE:
(818) 596-4493
LICENSING EVALUATOR NAME:
Christine Yee
TELEPHONE:
(747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE:
09/25/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/25/2023
LIC809
(FAS) - (06/04)
Page:
8
of
18
Document Has Been Signed on
09/26/2023 12:53 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 N.ASC
,
21731 VENTURA BLVD. #250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
ARARAT BOARD AND CARE
FACILITY NUMBER:
197609829
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/25/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above per review of posting, that the facility does not have the required complaint poster meeting the above requirements posted in the main entry way of the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/03/2023
Plan of Correction
1
2
3
4
Licensee will download PUB475 and print the poster in the required size of 20" x 26" and post in the main entryway for viewing by residents, representatives and the public by 10/3/23
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:
Kristin Heffernan
TELEPHONE:
(818) 596-4493
LICENSING EVALUATOR NAME:
Christine Yee
TELEPHONE:
(747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE:
09/25/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/25/2023
LIC809
(FAS) - (06/04)
Page:
9
of
18
Document Has Been Signed on
09/26/2023 12:53 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 N.ASC
,
21731 VENTURA BLVD. #250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
ARARAT BOARD AND CARE
FACILITY NUMBER:
197609829
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/25/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(4)
Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (4) To be informed by the licensee of the provisions of law regarding complaints and of procedures for confidentially registering complaints, including, but not limited to, the address and telephone number for the complaint receiving unit of the Department, and how to contact the Community Care Licensing Division of the California Department of Social Services, and the long-term care ombudsman regarding grievances in regard to the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above that there is no poster or information posted for contacting Community Care Licensing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/03/2023
Plan of Correction
1
2
3
4
Licensee will post information for contacting Community Care Licensing and procedures for registering complaints and the Long Term Care Ombudsman regarding grievances in regard to the facility
Section Cited
Additional Personal Rights of Residents in Privately Operated Facilities
Deficient Practice Statement
1
2
3
4
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
1
2
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:
Kristin Heffernan
TELEPHONE:
(818) 596-4493
LICENSING EVALUATOR NAME:
Christine Yee
TELEPHONE:
(747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE:
09/25/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/25/2023
LIC809
(FAS) - (06/04)
Page:
10
of
18
Document Has Been Signed on
09/26/2023 12:53 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 N.ASC
,
21731 VENTURA BLVD. #250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
ARARAT BOARD AND CARE
FACILITY NUMBER:
197609829
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/25/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.267(d)
Resident's Bill of Rights
(d) The licensee shall provide initial and ongoing training for all members of its staff to ensure that residents’ rights are fully respected and implemented.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above per request to review facility training logs and Licensee was not able to provide evidence of ongoing taff training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/03/2023
Plan of Correction
1
2
3
4
Licensee will locate records of staff training provided and make it available for Licensing review by 10/3/23
Type B
Section Cited
HSC
1569.157(f)(3)
Licensing
(3) If a facility does not have a resident council, upon admission, the facility shall provide written information on the resident’s right to form a resident council to the resident and the resident representative, as indicated in the admissions agreement.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and observation, the licensee did not comply with the section cited above per review of the Admission Agreement and postings, there is no information provided by the facility regarding the formation of a resident council provided in the Admission Agreement or posted in the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/03/2023
Plan of Correction
1
2
3
4
LIcensee will post information regarding the resident's right to form a resident council
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:
Kristin Heffernan
TELEPHONE:
(818) 596-4493
LICENSING EVALUATOR NAME:
Christine Yee
TELEPHONE:
(747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE:
09/25/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/25/2023
LIC809
(FAS) - (06/04)
Page:
11
of
18
Document Has Been Signed on
09/26/2023 12:53 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 N.ASC
,
21731 VENTURA BLVD. #250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
ARARAT BOARD AND CARE
FACILITY NUMBER:
197609829
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/25/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.157(h)
Licensing
(h) The text of this section with the heading “Rights of Resident Councils” shall be posted in a prominent place at the facility accessible to residents, family members, and resident representatives.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above per review of posting, there is no Rights of Resident Council posted in a prominant place at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/03/2023
Plan of Correction
1
2
3
4
Type B
Section Cited
HSC
1569.158(d)
Licensing
(d) Family councils shall be provided adequate space on a prominent bulletin board or other posting area for the display of meeting notices, minutes, information, and newsletters.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above per inspection of the facility postings that there is no information posted regarding the right to create a family council which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/03/2023
Plan of Correction
1
2
3
4
Licensee will post information regarding the formation of a family council by 10/3/23
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:
Kristin Heffernan
TELEPHONE:
(818) 596-4493
LICENSING EVALUATOR NAME:
Christine Yee
TELEPHONE:
(747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE:
09/25/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/25/2023
LIC809
(FAS) - (06/04)
Page:
12
of
18
Document Has Been Signed on
09/26/2023 12:53 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 N.ASC
,
21731 VENTURA BLVD. #250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
ARARAT BOARD AND CARE
FACILITY NUMBER:
197609829
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/25/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.158(g)(2)
Licensing
(2) If a facility does not have a family council, the facility shall provide, upon admission of a new resident, written information to the resident’s family or resident representative of their right to form a family council.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above per review of resident records and Admission Agreement that there is no written information provided to the families regarding the right to form a family council which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/03/2023
Plan of Correction
1
2
3
4
Licensee will ensure that all new residents, their families and representatives are proviided with written information of their right to form a family council by 10/3/23
Type B
Section Cited
HSC
1569.319(a)
Regulations
(a) A licensee of a facility that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for resident use.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above per information provided during the interview that the Administrator did not know that a dedicated computer, tablet or any internet access device that can support real time interactive application, equipped with videoconferencing was to be provided for resident use and no one asked which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/03/2023
Plan of Correction
1
2
3
4
Licensee will provide the residents with a computer, tablet o any internet access device capable of supporting real time interactive application, equipped with videoconferencing technology, dedicated for their use by 10/3/23
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:
Kristin Heffernan
TELEPHONE:
(818) 596-4493
LICENSING EVALUATOR NAME:
Christine Yee
TELEPHONE:
(747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE:
09/25/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/25/2023
LIC809
(FAS) - (06/04)
Page:
13
of
18
Document Has Been Signed on
09/26/2023 12:53 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 N.ASC
,
21731 VENTURA BLVD. #250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
ARARAT BOARD AND CARE
FACILITY NUMBER:
197609829
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/25/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.319(b)(1)
Regulations
(b) A licensee shall ensure the following requirements are met in providing any internet access device for resident use: (1) The device shall be available in a manner that allows a resident to access it for discussion of personal or confidential information with a reasonable level of personal privacy.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above per information provided during the interview that the facility does not have a plan in place that will allow residents to access the device for discussion of personal or confidential information with a reasonable level of personal privacy which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/03/2023
Plan of Correction
1
2
3
4
Licensee will provide the Department with a plan that will address how the internet access device will be made available in a manner that will allow residents to access the device with personal privacy by 10/3/23
Type B
Section Cited
HSC
1569.319(b)(2)
Regulations
(b) A licensee shall ensure the following requirements are met in providing any internet access device for resident use: (2) The device shall be made available to residents in a manner that permits shared access among all residents in the facility during reasonable hours.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the Licensee did not comply with the section cited above per information provided that the facility does not have a plan in place to ensure that the device is available to residents in a manner that permits shared access among the residentsi in the facility during reasonable hours, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/03/2023
Plan of Correction
1
2
3
4
Licensee will put together a plan that will permit all facility residents shared access to the internet access device during reasonable hours by 10/3/23
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:
Kristin Heffernan
TELEPHONE:
(818) 596-4493
LICENSING EVALUATOR NAME:
Christine Yee
TELEPHONE:
(747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE:
09/25/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/25/2023
LIC809
(FAS) - (06/04)
Page:
14
of
18
Document Has Been Signed on
09/26/2023 12:53 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 N.ASC
,
21731 VENTURA BLVD. #250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
ARARAT BOARD AND CARE
FACILITY NUMBER:
197609829
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/25/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(8)(A)
Incidental Medical and Dental Care Services
(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above since the Licensee could not provide a copy of the First Aid Manual to LPA for review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/03/2023
Plan of Correction
1
2
3
4
Licensee will purchase a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal agency and maintain in the facility by 10/3/23
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above per review of medications for Resident #****, medications were prepared and stored in 2 pill boxes labeled Monday through Sunday which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/03/2023
Plan of Correction
1
2
3
4
Licensee will review Title 22, Section 87465 - Incidental Medical and Dental Care and submit a written statement that the section was read and understood and will be adhered to at all times by 10/3/23
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:
Kristin Heffernan
TELEPHONE:
(818) 596-4493
LICENSING EVALUATOR NAME:
Christine Yee
TELEPHONE:
(747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE:
09/25/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/25/2023
LIC809
(FAS) - (06/04)
Page:
15
of
18
Document Has Been Signed on
09/26/2023 12:53 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 N.ASC
,
21731 VENTURA BLVD. #250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
ARARAT BOARD AND CARE
FACILITY NUMBER:
197609829
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/25/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(b)
Incidental Medical and Dental Care Services
(b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above per review or of Resident #6 file, it was observed that there is no PRN Authorization letter on file to establish that the physician has determined that Resident #6, who is diagnosed with Alzheimer, is able to to determine his/her need for the PRN Medication - Acetominophen, SM Stool Softener and Vitamin B-1 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/03/2023
Plan of Correction
1
2
3
4
Licensee will contact the prescribing physician and obtain a completed PRN Authorization Letter to confirm whether Resident #6 can or cannot determine his/her need for the PRN medication and maintain in the resident's file.
Section Cited
Incidental Medical and Dental Care Services
Deficient Practice Statement
1
2
3
4
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
1
2
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:
Kristin Heffernan
TELEPHONE:
(818) 596-4493
LICENSING EVALUATOR NAME:
Christine Yee
TELEPHONE:
(747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE:
09/25/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/25/2023
LIC809
(FAS) - (06/04)
Page:
16
of
18
Document Has Been Signed on
09/26/2023 12:53 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 N.ASC
,
21731 VENTURA BLVD. #250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
ARARAT BOARD AND CARE
FACILITY NUMBER:
197609829
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/25/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
87355 Criminal Record Clearance
(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:
(1) Obtain a California clearance or a criminal record exemption as required by the Department or
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and interview, the licensee did not comply with the section cited above per information obtained, Ashkhik Kebabjian, present at the facility for her first day of work today-9/25/23, was not cleared and associated to the facility prior to being present at the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
09/27/2023
Plan of Correction
1
2
3
4
Licensee will ensure that all staff, volunteers and persons who are required to obtain a criminal record clearance have obtained the required clearance and is associated to the facility before being present at the facility. Licensee will provide a plan of action that will be adhered to, to ensure all person are cleared and associated prior to being at the facility by 9/27/23. CIVIL PENALTIES WERE ASSESSED.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
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:
Kristin Heffernan
TELEPHONE:
(818) 596-4493
LICENSING EVALUATOR NAME:
Christine Yee
TELEPHONE:
(747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE:
09/25/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/25/2023
LIC809
(FAS) - (06/04)
Page:
17
of
18
Document Has Been Signed on
09/26/2023 12:53 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 N.ASC
,
21731 VENTURA BLVD. #250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
ARARAT BOARD AND CARE
FACILITY NUMBER:
197609829
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/25/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(j)
87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above per tour of the physical plant, all fiive doors exiting to the outside were not equipped with auditory devices and the facility retains residents with dementia which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/03/2023
Plan of Correction
1
2
3
4
Licensee will install auditory devices or other staff allert features on all doors that exit to the outside by 10/3/23
Type B
Section Cited
CCR
87465(e)(1-4)
Incidental Medical and Dental Care (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. (1) The specific symptoms which indicate the need for the use of the medication.(2) The exact dosage. (3) The minimum number of hours between doses.(4) The maximum number of doses allowed in each 24-hour period
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record reivew, the licensee did not comply with the section cited above per information reviewed revealed that the facility does not have any physician's orders on file for any of the centrally stored medications] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/10/2023
Plan of Correction
1
2
3
4
The Licensee will contact the prescribing physician or dispensing pharmacy to obtain a copy of the physician's order for all centrally stored medications and maintain in the residents files by 10/10/23. Licensee will self certify that all physicians orders have been obtained.
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:
Kristin Heffernan
TELEPHONE:
(818) 596-4493
LICENSING EVALUATOR NAME:
Christine Yee
TELEPHONE:
(747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE:
09/25/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/25/2023
LIC809
(FAS) - (06/04)
Page:
18
of
18