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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609877
Report Date: 06/14/2021
Date Signed: 06/14/2021 04:43:36 PM

Document Has Been Signed on 06/14/2021 04:43 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:IN HOME CARE CENTERFACILITY NUMBER:
197609877
ADMINISTRATOR:DOVLATYAN, KRISTINEFACILITY TYPE:
740
ADDRESS:9023 GAVIOTA AVETELEPHONE:
(747) 998-7577
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 6; 6CENSUS: 5DATE:
06/14/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Kristine DovlatyanTIME COMPLETED:
03:06 PM
NARRATIVE
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Licensing Program Analyst (LPA) Martina Berry conducted a case management visit to address deficiencies observed during a subsequent complaint visit on 6/14/2021. The LPA met with Administrator Kristine Dovlatyan to conduct an entrance interview.

During the facility tour, the LPA toured the kitchen at 9:20 AM. The LPA observed a couch and bed located in the kitchen area. The LPA interviewed S1 at 9:30 AM. S1 reported that that they sleep in the kitchen area. The LPA also interviewed the Administrator at 11:35 AM. The Administrator reported that staff use the bed and couch located in the kitchen area to rest or sleep in between shifts. According to Title 22 Regulations 87303 (a), " 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..."

Deficiency cited. The LPA conducted an exit interview with Administrator Kristine Dovlatyan and discussed a plan of correction. A copy of this report was provided via email. .
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Martina Berry
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2021
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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Document Has Been Signed on 06/14/2021 04:43 PM - It Cannot Be Edited


Created By: Martina Berry On 06/14/2021 at 02:27 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: IN HOME CARE CENTER
FACILITY NUMBER: 197609877

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/15/2021
Section Cited
CCR
87307(a)

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Personal Accommodations and Services
"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..."
This requirement was not met as evidenced by:
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The Licensee will remove the bed and couch from the kitchen. The Licensee will send an updated facility sketch and updated plan regarding the use of staff area in the facility.
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The Licensee did not ensure that staff accommodations were provided according to Title 22 Regulations. This poses a potential risk to the health and safety of 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:Cassandra Harris
LICENSING EVALUATOR NAME:Martina Berry
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2021


LIC809 (FAS) - (06/04)
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