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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609889
Report Date: 02/16/2022
Date Signed: 02/16/2022 01:06:11 PM

Document Has Been Signed on 02/16/2022 01:06 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: 3DATE:
02/16/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Irina KarbachinskiyTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced case management visit. LPA was joined by Long Term Care Ombudsman (LTCO) Ginger Perini and Erin Pickerel during this visit.

Upon entry to the facility LPA conducted a physical plant walk through to ensure no immediate health and safety issues. LTCO conducted interviews with residents in the facility while LPA conducted a walk through of the facility. During the course of the visit LPA observed that the administrator's administrator certificate had expired as of 8/8/2020. Facility was previously cited on 11/8/21 regarding the expired administrator's certificate. Administrator still has not renewed their administrator's certificate.
During the course of the visit LPA and LTCO spoke with the administrator regarding the facilities policy on residents leaving the facility, Activities for residents in the facilities, and LTCO's role when visiting the facility.
During the visit the administrator was given an LTCO Poster which was posted during the visit.

Exit Interview conducted. Copy of report emailed to administrator.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2022
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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Document Has Been Signed on 02/16/2022 01:06 PM - It Cannot Be Edited


Created By: Wendell Smith On 02/16/2022 at 11:18 AM
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: 02/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/18/2022
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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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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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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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:Wendell Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2022


LIC809 (FAS) - (06/04)
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