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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609860
Report Date: 11/07/2024
Date Signed: 11/13/2024 09:08:57 AM

Document Has Been Signed on 11/13/2024 09:08 AM - 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:AMAZING SENIOR CARE, INCFACILITY NUMBER:
197609860
ADMINISTRATOR/
DIRECTOR:		ANNA PETROSYANFACILITY TYPE:
740
ADDRESS:16938 CITRONIA STREETTELEPHONE:
(818) 853-6695
CITY:NORTHRIDGESTATE: CAZIP CODE:
91343
CAPACITY: 6CENSUS: 6DATE:
11/07/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Yelena Aladadyan- AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPAs) Leslie Ngo-Castaneda and Huma Rahimi conducted an continuation annual required visit and inspection of the facility. At 11:40 AM Yelena Aladayan who is the administrator met with LPA, explained the reason for the visit.

At 11:45 AM, with the assistance of administrator, LPAs took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are operational that are located each bedroom, the hallway and kitchen. There are carbon monoxide detectors that functions properly. The fire extinguisher is in the kitchen. The charge date is 11/01/2023. During the visit the facility is at 74 degrees Fahrenheit. The facility is fire cleared for six (06) non-ambulatory residents.

Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPAs found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked drawer in the kitchen. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Cleaning supplies, pesticides or toxic cleaning supplies were stored and not locked away in the kitchen. Citation will be issued in LIC 809-D.

Bedrooms: There were four (4) bedrooms designated for residents' use. Bedroom #2 and bedroom #4 are private, but bedroom #1 and bedroom #3 are shared. All of the bedrooms are used by residents were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting.

Continue to LIC 809-C
Nichelle Gillyard
Leslie Ngo-Castaneda
DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AMAZING SENIOR CARE, INC
FACILITY NUMBER: 197609860
VISIT DATE: 11/07/2024
NARRATIVE
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Bathrooms: There are two (2) bathroom designated for residents' use. The bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 109.6 degrees Fahrenheit for bathroom #1 located in the hallway beside room #1. Bathroom #2 is inside bedroom #3. Hot water temperature was measured at 112.8 degrees Fahrenheit. There was enough clean linen available in the cabinets in the hallway.

Common Areas: LPA toured all common areas of the facility. These included the living room and dining area for residents. The common areas were properly furnished. Residents dining table fits enough for six (6). LPA observed common areas to be very clean and tidy. LPA observed the floors to be in very good condition. No obstructions and or tripping hazards throughout the facility. Furniture in common area was observed to be in good repair. There are no issues with Fire Clearance.

Infection control: Facility mitigation plan to make sure licensee was following current infection control recommendations. LPA obtain a copy and reviewed the infection control plan during this visit.

Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The facility has a swimming pool, it is locked and fenced up. The garage is attached and is used for storage. LPA found expired medication from previous resident who had passed. Deficiency will be cited on LIC 809-D.

Laundry service: There is enough linen available to change weekly or more if need. LPA found cleaning supplies are being stored in an unlocked cabinet in the laundry area and is located beside the kitchen. Deficiency will be cited on LIC 809-D.

Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Office space is beside the dining table. Records were checked for expired or missing certificates and clearances: LPA conducted a file review of staff for criminal record clearances and current First Aid. LPA did a record review for S4 file and their missing a current CPR training. Citation will be issued in LIC 809- D. The administrator file was reviewed for current first aid, fingerprint clearance, administrator certificate, and HIV/AIDS and TB training.

Continue to LIC 809-C
SUPERVISOR'S NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AMAZING SENIOR CARE, INC
FACILITY NUMBER: 197609860
VISIT DATE: 11/07/2024
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Medications: LPAs observed that the medication are kept in the living room in a locked cabinet and inaccessible to residents in care, however, review of R1's random medication revealed that the facility was supposed to start Quetiapin Fumarate 25 MG (schizophrenia and bipolar disorder) a new bubble pack on 10/20/2024. During today's visit LPAs counted R1's medication and it was discovered that there was a discrepancy, and three (3) extra pills were in the bubble pack. LPA asked the Administrator and the staff for explaining and both staff could not provide any answers. Additionally, LPAs also observed Centrally Stored Medication (LIC 622) records for R5 and did not observe staff filling the form when the medication start date. A deficiency will be cited. First-aid has all proper items and is current.

Resident records were reviewed for requirements and legibility: Planned activities are offered. LPA reviewed six (6) of the six (6) records and LPA found all files to be complete.

Facility is within CA code of Regulations Title 22 or Health and Safety Code. Deficiencies were found, exit interview conducted, copy of report has been issued and discussed.
SUPERVISOR'S NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 11/13/2024 09:08 AM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 11/07/2024 at 12:31 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: AMAZING SENIOR CARE, INC
FACILITY NUMBER: 197609860

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in 1 out of 1 staff left the storage unlock for checmicals; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
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Administrator needs to ensure that storage is lock and inaccessible to clients where chemicals are accessible.
Type A
Section Cited
CCR
87309(a)(1)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in 1 out of 1 staff left the storage unlock for checmicals; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
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Administrator needs to ensure that storage is lock and inaccessible to clients where chemicals are accessible.
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/13/2024 09:08 AM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 11/07/2024 at 01:16 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: AMAZING SENIOR CARE, INC
FACILITY NUMBER: 197609860

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)


This requirement is not met as evidenced by: 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.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 staff medication was seen seen bedroom #2 and bedroom #3 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
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Staff medication should not be in residents bedroom, this hsould be locked and inaccessible to residents.
Type A
Section Cited
CCR
87465(c)(2)


This requirement is not met as evidenced by: c) If the resident's physician has stated in writing... 2) Once ordered by the physician the medication is given according to the physician's directions.

Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in not assuring that R1's prescribed medications were given as prescribed, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/12/2024
Plan of Correction
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Administrator agreed to schedule vendorized training for all staff by 11/12/2024 and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion. Administrator also agreed to notify doctor and submit LIC 624 to CCL regarding the incident.
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 11/13/2024 09:08 AM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 11/07/2024 at 01:24 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: AMAZING SENIOR CARE, INC
FACILITY NUMBER: 197609860

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)


This requirement is not met as evidenced by: Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above in 1 out of 1 staff was found sleeping in bedroom #3, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2024
Plan of Correction
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Staff needs to be relocated and find a new place to reside, not in the facility.
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 11/13/2024 09:08 AM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 11/07/2024 at 01:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: AMAZING SENIOR CARE, INC
FACILITY NUMBER: 197609860

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(c)(1)


This requirement is not met as evidenced by: All RCFE staff who assist residents with personal activities & annual training as specified in Health and Safety Code sections…(1)Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
Deficient Practice Statement
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Based on the LPAs record review, the licensee did not comply with the section cited above. One caregiver has not completed the CPR and first aid training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/12/2024
Plan of Correction
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The Licensee will send a copy of the caregiver's certificate of completion of the CPR and first aid training via email to LPA Ngo-Castaneda.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024


LIC809 (FAS) - (06/04)
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