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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609889
Report Date: 06/29/2021
Date Signed: 06/29/2021 04:34:50 PM

Document Has Been Signed on 06/29/2021 04:34 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:PEARL OF WEST HILLS, INCFACILITY NUMBER:
197609889
ADMINISTRATOR:IRINA, KARBACHINSKIYFACILITY TYPE:
740
ADDRESS:23427 VICTORY BLVDTELEPHONE:
(818) 854-6306
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY: 6CENSUS: 6DATE:
06/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:48 PM
MET WITH:Irina KarbchinskiyTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angelica Arambulo conducted an unannounced required annual visit. LPA introduced herself and met with Licensee irina Karbachinskiy and informed her of the purpose of the visit.

Upon entry LPA was screened for covid symptoms. LPA requested a copy of the mitigation plan. Licensee was not sure what that was. LPA reviewed facility file on 4-7-2021 AGPA returned an incomplete mitigation plan to be resubmitted by 4-15-21. Licensee states she never sent the paperwork back even after talking to a consultant to complete it. She assumed since her LPA did not contact her everything was ok. Citation is issued for failure to complete and submit a mitigation plan for approval.

A tour was taken of the facility and LPA observed all residents accommodations.. The new staff working did not have a complete staff file such as physician report, orientation training, application, employee rights, fingerprint clearance shows not received. A letter of Clearance was shown to LPA by licensee for Care Provider Management Bureau. LPA advised Licensee to contact Guardian regarding the clearance and get back to LPA.

Citations issued, appeal rights given, exit interview.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Angelica Arambulo
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2021
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 06/29/2021 04:34 PM - It Cannot Be Edited


Created By: Angelica Arambulo On 06/29/2021 at 03:55 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: PEARL OF WEST HILLS, INC
FACILITY NUMBER: 197609889

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(A)(2)


This requirement is not met as evidenced by: The Licensee never submitted a completed Mitigation plan which was last requested on 4-7-2021 and due by 4-21-2021
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2021
Plan of Correction
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Licensee shall submit a completed mitigation plan to LPA by the due date. Failure to do so may lead to civil penalties.
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:Eva Miller
LICENSING EVALUATOR NAME:Angelica Arambulo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/29/2021 04:34 PM - It Cannot Be Edited


Created By: Angelica Arambulo On 06/29/2021 at 04:13 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: PEARL OF WEST HILLS, INC
FACILITY NUMBER: 197609889

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a,b,c)


This requirement is not met as evidenced by: Staff file is incomplete. Missing health screening, application, employee rights, copy of his first aid card.
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2021
Plan of Correction
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Licensee will submit copies of Staffs completed file by the due date.
Section Cited
Deficient Practice Statement
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4
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:Eva Miller
LICENSING EVALUATOR NAME:Angelica Arambulo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2021


LIC809 (FAS) - (06/04)
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