197609891-10-3-2024-31-AS-LNCA-D9PUVE-20241003155502

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609891
Report Date: 10/03/2024
Date Signed: 10/03/2024 03:55:15 PM

Document Has Been Signed on 10/03/2024 03:55 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ANGELES ASSISTED LIVING		FACILITY NUMBER:	197609891
ADMINISTRATOR:	ASATRYAN, YULIYA		FACILITY TYPE:	740
ADDRESS:	15942 BAHAMA STREET		TELEPHONE:	(818) 891-4183
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY:	6	CENSUS: 6	DATE:	10/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:53 PM
MET WITH:	Yuliya Asatryan- Administrator		TIME COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an annual required visit and inspection of the facility. LPA met with staff Joyce San Pedro, explained the reason for the visit. At 1:05 PM Yuliya Asatryan who is the administrator met with LPA, explained the reason for the visit. At 1:02 PM, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are operational that are located each bedroom, the hallway and kitchen. There are carbon monoxide detectors that functions properly. The fire extinguisher is in the kitchen. The charge date is 12/28/2023. During the visit the facility is at 74 degrees Fahrenheit. The facility is fire cleared for six (06) non-ambulatory residents; 6 maybe bedridden; 4 hospice waiver. Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked drawer in the kitchen. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Cleaning supplies, pesticides or toxic cleaning supplies were stored and locked away in the kitchen cabinet. Bedrooms: There were five (5) bedrooms designated for residents' use. Bedroom #1 is shared, bedroom #2, bedroom #3, bedroom #4, and bedroom #5 is private, the bedrooms are used by residents were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Continue to LIC 809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda	TELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANGELES ASSISTED LIVING	FACILITY NUMBER: 197609891
	VISIT DATE: 10/03/2024

NARRATIVE

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Bathrooms: There are three (3) bathroom designated for residents' use. The bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 105.1 degrees Fahrenheit for bathroom #1 located in the hallway beside bedroom #5. Bathroom #2 is beside bedroom #4. Hot water temperature was measured at 105.4 degrees Fahrenheit. Bathroom #3 is inside bedroom #1. Hot water temperature was measured at 107 degrees Fahrenheit. There was enough clean linen available in the cabinets in the hallway. LPA found scissor and razor in bathroom, deficiency will be cited on LIC 809-D.

Common Areas: LPA toured all common areas of the facility. These included the living room and dining area for residents. The common areas were properly furnished. Residents dining table fits enough for six (6). LPA observed common areas to be very clean and tidy. Fire place is closed, non-operational, and blocked. LPA observed the floors to be in very good condition. No obstructions and or tripping hazards throughout the facility. Furniture in common area was observed to be in good repair. There are no issues with Fire Clearance.

Infection control: Facility mitigation plan to make sure licensee was following current infection control recommendations. LPA obtain a copy and reviewed the infection control plan during this visit.

Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The facility does not have a swimming pool or body of water. The garage is attached and was lock and is used for storage for PPE and cleaning supplies.

Laundry service: There is enough linen available to change weekly or more if need. Cleaning supplies are being stored in lock storage in the laundry area and is located in the garage.

Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Office space is by the hallway. Records were checked for expired or missing certificates and clearances: LPA conducted a file review of staff for criminal record clearances, training, health screening, TB test, and current First Aid.

Continue to LIC 809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda	TELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANGELES ASSISTED LIVING	FACILITY NUMBER: 197609891
	VISIT DATE: 10/03/2024

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Medications are in a centrally stored and not in a locked place, including over-the-counter medicines; medications are properly labeled and checked for expiration dates. S2, R4 and R5 medication were seen at the kitchen cabinet and resident bedroom dresser. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the clients’ doctor. Proper medication dispensing instruction are followed and checked for contamination. First-aid has all proper items and current.

Resident records were reviewed for requirements and legibility: LPA reviewed client’s files for current plan. Planned activities are offered.

Deficiencies are cited in LIC 809-D. Appeal rights are explained. Exit interview conducted, copy of report has been issued and discussed.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda	TELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/03/2024 03:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANGELES ASSISTED LIVING	FACILITY NUMBER: 197609891
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)(1)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. 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 1 scissor and razor which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/04/2024
	Plan of Correction
1 2 3 4	Administrator need to lock hazardous objects that are accessible to residents. POC will be cleared today, staff lock away the items.

Type A

Section Cited

CCR

87309(b)

Storage Space

(b) Medicines shall be stored as specified in Section 87465(c) and separately from other items specified in (a) above. 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 3 out of 3 resdidets medication and supplements are accessible, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/04/2024
	Plan of Correction
1 2 3 4	Administrator need to lock medication and supplements that are accessible to residents. POC will be cleared today, staff lock away the medication approproately.

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: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda	TELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/03/2024 03:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANGELES ASSISTED LIVING	FACILITY NUMBER: 197609891
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.695(a)(7)(E)

Other Provisions

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (7) Procedures that address, but are not limited to, all of the following: (E) Storage and preservation of medications, including the storage of medications that require refrigeration. 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 1 eye drops were not locked and accessible in the refrigerator, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/04/2024
	Plan of Correction
1 2 3 4	Administrator need to lock medications that are in the refrigerator so that it would not be accessible to residents. POC will be cleared today, staff lock away the items.

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: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda	TELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

LIC809 (FAS) - (06/04)

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