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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609891
Report Date: 03/12/2024
Date Signed: 03/12/2024 02:13:10 PM


Document Has Been Signed on 03/12/2024 02:13 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 LIVINGFACILITY NUMBER:
197609891
ADMINISTRATOR:ASATRYAN, YULIYAFACILITY TYPE:
740
ADDRESS:15942 BAHAMA STREETTELEPHONE:
(818) 891-4183
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 6DATE:
03/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:Yuliya Asatryan- AdministratorTIME COMPLETED:
02:30 PM
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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 10:00 am Yuliya Asatryan who is the administrator met with LPA, explained the reason for the visit.

At 10:57 am, with the assistance of administrator, 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 73 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 cabinet in the kitchen. The menu was posted on the refrigerator for review, snacks and beverages are available for the resident in the facility when they want. 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, but the storage in the garage is kept unlock, which is accessible to the residents.

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 GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-CastanedaTELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 9


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: 03/12/2024
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 106.1 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 107.6 degrees Fahrenheit. There was enough clean linen available in the cabinets in the hallway.

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 UNLOCK and is used for storage for PPE and cleaning supplies. Citation will be issued in LIC 809-D.

Laundry service: There is enough linen available to change weekly or more if need. Cleaning supplies are being stored in UNLOCK storage in the laundry area and is located in the garage. Citation will be issued in LIC 809-D

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 and current First Aid. Staff is missing LIC 9052 for two staff and the administrator file was NOT reviewed, file is not available in the facility, citation will be cited in LIC 809-D. Continue to LIC 809-C
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-CastanedaTELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 9
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: 03/12/2024
NARRATIVE
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Medications are in a centrally stored and locked place, including over-the-counter medicines; medications are properly labeled and checked for expiration dates. 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. LPA reviewed all of residents file and one (1) of the six (6) residents file are missing appraisal.

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 GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-CastanedaTELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 03/12/2024 02:13 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: 03/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, the licensee did not comply with the section cited above in 1 out of 1 lock which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2024
Plan of Correction
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Facility needs to change the door lock.
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: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-CastanedaTELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024
LIC809 (FAS) - (06/04)
Page: 3 of 9


Document Has Been Signed on 03/12/2024 02:13 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: 03/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(6)(A)
Personnel Records
(A) For administrators this shall include verification that he/she meets the educational requirements in Section 87405(d) through (g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 1 records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2024
Plan of Correction
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Administrator file needs to be in facility.
Type B
Section Cited
CCR
87412(d)
Personnel Records
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 1 records are not available for LPA to review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2024
Plan of Correction
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Administrator file needs to be in facility.
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 GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-CastanedaTELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024
LIC809 (FAS) - (06/04)
Page: 4 of 9


Document Has Been Signed on 03/12/2024 02:13 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: 03/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.313
Regulations
Each residential care facility for the elderly shall state, on its client information form or admission agreement, and on its patient’s rights form, the facility’s policy concerning family visits and other communication with resident clients and shall promptly post notice of its visiting policy at a location in the facility that is accessible to residents and families. The facility’s policy concerning family visits and communication shall be designed to encourage regular family involvement with the resident client and shall provide ample opportunities for family participation in activities at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 1 physicians report and TB which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2024
Plan of Correction
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Facility needs to have LIC 601, physician report and TB test in file.
Type B
Section Cited
CCR
87506(b)(13)
Resident Records
(b) Each resident's record shall contain at least the following information: (13) Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or the services he needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 1 physician report and TB test which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2024
Plan of Correction
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Facility needs to have physician report and TB test in file.
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 GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-CastanedaTELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024
LIC809 (FAS) - (06/04)
Page: 5 of 9


Document Has Been Signed on 03/12/2024 02:13 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: 03/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(17)(A)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (A) Section 87457, Pre-Admission Appraisal;

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 1 persons appraisal is not done which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2024
Plan of Correction
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Please have appraisal made when taking in new resident.
Type B
Section Cited
CCR
87506(b)(17)(B)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (B) Section 87459, Functional Capabilities;

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 1 resident does not have functional capabilities, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2024
Plan of Correction
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4
Please have appraisal made when taking in new resident.
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 GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-CastanedaTELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024
LIC809 (FAS) - (06/04)
Page: 6 of 9


Document Has Been Signed on 03/12/2024 02:13 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: 03/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 1 resdeint appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2024
Plan of Correction
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2
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4
Appraisal needs to be done when taking in new resident.
Type B
Section Cited
CCR
87457(c)(1)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 resident records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2024
Plan of Correction
1
2
3
4
Apparaisal needs to be done when taking in new resident.
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 GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-CastanedaTELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024
LIC809 (FAS) - (06/04)
Page: 7 of 9


Document Has Been Signed on 03/12/2024 02:13 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: 03/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

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 1 administator file was not avaiable in facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2024
Plan of Correction
1
2
3
4
Administrator file needs to be in the facility.
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 GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-CastanedaTELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024
LIC809 (FAS) - (06/04)
Page: 9 of 9