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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609877
Report Date: 03/06/2023
Date Signed: 03/06/2023 01:30:17 PM

Document Has Been Signed on 03/06/2023 01:30 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: 6CENSUS: 5DATE:
03/06/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH: Kristine DovlatyanTIME COMPLETED:
01:35 PM
NARRATIVE
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Licensing Program Analysts (LPA) Tihesha Smith conducted a Case Management Deficiencies visit in conjunction with a complaint to address deficiencies observed during the investigation of complaint control # 31-AS-20230227123033.

At approximately 10:30 am LPA Smith conducted physical tour. LPA observed a convertible couch made up as a bed with blankets, linens and pillow in the kitchen area. Staff #2 (S2) removed linens and put convertible couch in seating position. LPA interviewed staff from 11:00am -1240 pm. Per interviews (S2) stated they use the bed in the kitchen to sleep sometimes.



A deficiency is cited on an LIC 809-D page.

Exit interview was conducted, appeal rights and copy of report issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2023
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 03/06/2023 01:30 PM - It Cannot Be Edited


Created By: Tihesha Smith On 03/06/2023 at 01:05 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: 03/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/07/2023
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/Administrator will remove convertible couch from the kitchen and provided a picture of removal from kitchen. Licensee/Administrator will also send written plan on how will address staff accommodations/privacy. POC:03/07/2023
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The Licensee/Administrator did not ensure staff accommodations were provided. 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:Naira Margaryan
LICENSING EVALUATOR NAME:Tihesha Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2023


LIC809 (FAS) - (06/04)
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