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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609889
Report Date: 11/05/2021
Date Signed: 11/05/2021 04:52:07 PM

Document Has Been Signed on 11/05/2021 04:52 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:
11/05/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Irina KarbachinskiyTIME COMPLETED:
04:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yelena Avetisyan conducted an unannounced Virtual Case Management Deficiencies visit due to deficiencies observed during the investigation of complaint control 31-AS-20210416135138 on 4/20/2021.

Upon entrance to the facility LPA was greeted by 2 staff. At 3:35 pm LPA spoke with the licensee who stated that she would come to the facility shortly. Administrator arrived approximately 4:05 pm.

LPA held a discussion Ms. Karbachinskiy regarding the status of her administrator certificate. Per Licensee she has not completed all the required classes and has not hired a certified administrator to oversee the facility.

Prior to this visit LPA conducted a review of the licensing information system and obtained the names of all staff who are associated with the facility. Upon review of the records LPA observed that the 2 staff working at the facility are not associated with the facility. At 4:14 pm LPA called the Woodland Hills Regional office and clarified that staff 1 (S1) has criminal record clearance, however staff 2 (S2) does not have criminal record clearance. A discussion was held with the administrator regarding criminal record clearance requirements.

Exit interview conducted, copy of report, citations, civil penalties and appeal rights issued.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2021
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 11/05/2021 04:52 PM - It Cannot Be Edited


Created By: Yelena Avetisyan On 11/05/2021 at 04:30 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: 11/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/05/2021
Section Cited
CCR
87355(e)(2)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
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Licensee Irina Karbachinskiy provided transfer of criminal record clearance and photo ID to the LPA during the visit.
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Based on record review the licensee did not comply with the section cited above by not transferring criminal record clearance for staff 1 (S1) to this facility prior to employment which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
11/05/2021
Section Cited
CCR87355(e)(2)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Departmentr
This requirement is not met as evidenced by:
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Licensee Irina Karbachinskiy requested for staff member to leave the facility.

Licensee provided LPA a signed written statement that the staff # 2 will not return to the facility until criminal record clearance is obtained.
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Based on record review the licensee did not comply with the section cited above by not ensuring staff 2 (S2) obtained criminal record clearance prior to employment which poses an immediate health, safety or personal rights risk to persons 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:Eva Miller
LICENSING EVALUATOR NAME:Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/05/2021 04:52 PM - It Cannot Be Edited


Created By: Yelena Avetisyan On 11/05/2021 at 04:38 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: 11/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/08/2021
Section Cited
CCR
87406(g)

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87406 Administrator Certification Requirements (g) Certificates issued under this section shall be renewed every two (2) years provided the certificate holder has
complied with all renewal requirements.

This requirement is not met as evidenced by:
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This deficiency was cited on 4/20/2021. As of todays visit Licensee Irina Karbachinskiy confirmed that she has not completed all of the required classes to renew her certificate.
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Based on review of records and interview with licensee which revealed the Licensees Administrator Certificate expired 08/08/2020 and the Administrator has not taken the required classes to renew the required Administrator Certificate which poses an immediate health, safety and personal rights risk to residents in care.
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Licensee/Administrator will notify the department when they will renew their certificate and who will be the designated administrator for the facility while she completes the renewal process.

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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:Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2021


LIC809 (FAS) - (06/04)
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