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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609923
Report Date: 06/16/2023
Date Signed: 06/16/2023 01:35:06 PM


Document Has Been Signed on 06/16/2023 01:35 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. #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: 6DATE:
06/16/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Emma Arutiunian - AdministratorTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Brian Balisi conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control #29-AS-20220208161249). The purpose of the visit is to issue a citation for deficiencies observed during the complaint investigation.

During the complaint investigation, the following deficiency was observed: A Ring camera was observed installed on the ceiling of Resident 1 (R1). Administrator stated the responsible party installed the camera to keep in touch with R1. During the visit, Administrator called the responsible party over the phone and informed them they are required to remove the camera today. Responsible party agreed to visit facility today and remove camera. LPA did not observe cameras installed in the rooms of other residents in care.

Citations Issued.  See LIC 809-D.  Appeal Rights discussed and copy of report issued to Administrator.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023
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 2


Document Has Been Signed on 06/16/2023 01:35 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
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: 06/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/23/2023
Section Cited
CCR
87307(a)

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Living accommodations and grounds shall be related to the facility's function... privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply
This requirment was not met as evidenced by:
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During the visit, The reponsible party agreed to uninstall the camera today. Administrator agreed to review section cited and submit statement of understanding to LPA via email by POC date. Administrator will also send picture to LPA via email once camera is removed.
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During physical plant, LPA observed camera installed in R1's room. This poses as 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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023
LIC809 (FAS) - (06/04)
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