197609877-10-19-2022-31-AS-ERIS-CKCUAQ-20221019152507

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609877
Report Date: 10/19/2022
Date Signed: 10/19/2022 03:25:20 PM

Document Has Been Signed on 10/19/2022 03:25 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	IN HOME CARE CENTER		FACILITY NUMBER:	197609877
ADMINISTRATOR:	DOVLATYAN, KRISTINE		FACILITY TYPE:	740
ADDRESS:	9023 GAVIOTA AVE		TELEPHONE:	(747) 998-7577
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY: 6		CENSUS: 5	DATE:	10/19/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Kristine Dovlatyan		TIME COMPLETED:	03:30 PM

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Licensing Program Analysts (LPA) Evelin Rios conducted an Annual Required visit and inspection of the facility. LPA was granted access by staff Mariam Bejanyan and the administrator, Kristine Dovlaytan met us shortly after and LPA explained the reason for the visit.

At 12:00pm, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms and carbon monoxide detectors are dual an they are interconnected. The fire extinguisher is located by the living room, next to the kitchen. It is inspected every year last inspection on tag date is 3/09/2022.

Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked cabinet in the kitchen. Cleaning supplies also stored in and kept locked and inaccessible to the residents in kitchen cabinet.

Bedrooms: There were three (3) bedrooms designated for clients' use. All three bedrooms, were properly furnished with appropriate beddings and linens with sufficient lighting.

Bathrooms: There are two (2) bathrooms designated for clients' use. One (1) bathroom out of two (2) located in resident's room is designated for private use was properly supplied and had functional fixtures. Second bathroom was designated for all residents was properly supplied and had functional fixtures. Hot water temperature was measured between 117 degrees Fahrenheit.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022

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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: IN HOME CARE CENTER	FACILITY NUMBER: 197609877
	VISIT DATE: 10/19/2022

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Common Areas: These included the living room, dining area and laundry area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. Properly labeled medications were locked in a cabinet in the kitchen area. LPA observed One (1) out of five (5) resident’s refill medication was kept in a cabinet in the unlocked garage with access through the kitchen accessible to residents with Dementia. The laundry room is located by the kitchen and detergents and cleaning supplies are kept locked in a cabinet laundry room. Cleaning supplies also stored in the laundry area were kept locked and inaccessible to the residents.

Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. LPA observed a back-house with different address that is not part of facility. Side gate on the side of the home that leads to the front yard was closed but not locked and available for use in case of an emergency.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms. LPA observed One (1) out of the five (5) resident's files was missing a medical assessment / physician's report in file. Administrator could not produce the document on day of visit.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records were review for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiencies observed during the visit.

Exit Interview Conducted / Deficiencies cited noted on 809D / Appeals Rights discussed/ Copy of the Report Issued.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/19/2022 03:25 PM - It Cannot Be Edited

Created By: Evelin Rios On 10/19/2022 at 02:33 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: 10/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants 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 in 1 out of 5 resident's medication was keept in an unlocked cabniet in the unlocked garage that can be accessed by the kicten, accessable to residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/19/2022
	Plan of Correction
1 2 3 4	Administrator moved medication to locked storage cabinet by kitchen on day of visit to correct deficiency while LPA was there no POC issued.

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:

Eva Miller

LICENSING EVALUATOR NAME:

Evelin Rios

LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 10/19/2022 03:25 PM - It Cannot Be Edited

Created By: Evelin Rios On 10/19/2022 at 03:09 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: 10/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(a)

Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. 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 in 1 out of 5 resident's files which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/21/2022
	Plan of Correction
1 2 3 4	Licensee will send a copy of the most recent Medical Assessment / Physicians Report to LPA by 10/21/2022.

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:

Eva Miller

LICENSING EVALUATOR NAME:

Evelin Rios

LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022

LIC809 (FAS) - (06/04)

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