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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609923
Report Date: 11/06/2020
Date Signed: 11/06/2020 12:25:17 PM

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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:BASSETT RESIDENTIAL CAREFACILITY NUMBER:
197609923
ADMINISTRATOR:TAVITIAN, HRIPSIMEFACILITY TYPE:
740
ADDRESS:16017 BASSETT STTELEPHONE:
(818) 442-5702
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY:6CENSUS: 5DATE:
11/06/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Emma Arutiunian, lead caregiverTIME COMPLETED:
12:25 PM
NARRATIVE
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During an initial complaint visit for complaint #29-AS20201105122427, Licensing Program Analysts (LPAs) Kelly Dulek and Brian Balisi met with Emma Arutiunian, lead caregiver. During the course of the investigation, LPAs Dulek and Balisi observed deficiencies unrelated to the complaint allegation.

Upon arrival at the facility at 9:08am, LPAs observed staff #1 (S1) not wearing a mask when S1 answered the door, which is in violation of official government orders requiring the wearing of face coverings while working under specified conditions. Additionally, during the course of the visit, LPAs reviewed records and conducted an interview with the lead caregiver at 9:12am. Record review revealed there was no death report in the file for Resident #1 (R1). Interview with the lead caregiver revealed no death report was sent to the Regional Office for R1.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2020
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BASSETT RESIDENTIAL CARE
FACILITY NUMBER: 197609923
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/06/2020
Section Cited

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87468.1 Personal Rights of Residents in all Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidenced by:
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Based on observation, at 9:08am, 1 staff who was providng care and supervision to residents was observed without a face mask, in violation of official government orders requiring the wearing of face coverings while working under specified conditions, which poses an immediate health and safety risk to residents in care.
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Type B
11/13/2020
Section Cited

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87211(a)(1)(A) Reporting Requirements. (1) A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events...(D)Death of any resident from any cause regardless of where the death occurred…
This requirement is not met as evidenced by:
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Based on interview and record review; licensee failed to ensure proper reporting requirements were followed by failing to submit a death report for Resident 1 (R1) which poses a potential health and safety 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2020
LIC809 (FAS) - (06/04)
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