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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609923
Report Date: 07/17/2024
Date Signed: 07/17/2024 04:53:32 PM


Document Has Been Signed on 07/17/2024 04:53 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 N.ASC, 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:
07/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Emma ArutiunianTIME COMPLETED:
05:15 PM
NARRATIVE
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At 9:45 a.m. Licensing Program Analyst (LPA) Valeria Conway arrived at the facility to conduct the required annual inspection. LPA met with administrator Emma Arutiunian and explained the reason for the visit. At 11:30 a.m. back up administrator Ruzanna Manukyan arrived at he facility and joined the visit.

The LPA and the administrator conducted a tour of the physical plant at approximately 10:15 a.m. There are (6) bedrooms for residents and (1) bedroom for staff use only. At 10:52 a.m. smoke alarms and carbon monoxide detector were functioning at time of the visit. The LPA observed all required postings in the entry area. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Fire extinguisher was fully charged and purchased in April 11th 2024.

KITCHEN: The kitchen appeared clean and the appliances and fixtures functional during the time of visit, sharp objects are stored in lock box that was kept on the kitchen counter. The LPA observed box to be locked at this time. Some cleaning supplies and disinfectants were observed stored under the sink. The LPA observed the usage of a snap hook carabiner instead of lock. LPA explained Licensee the importance of having a lock to prevent access to cleaning supplies and toxins to residents with dementia. The LPA observed a sufficient amount of perishable and a seven-day supply of non-perishable food at the facility properly stored.

Continued on LIC 809-C
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria ConwayTELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2024
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 5


Document Has Been Signed on 07/17/2024 04:53 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: BASSETT RESIDENTIAL CARE
FACILITY NUMBER: 197609923

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87204(b)
Limitations -Capacity and Ambulatory Status
(b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nonambulatory shall not remain in rooms restricted to ambulatory residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by having residents in incorrect rooms, non-ambulatory in ambulatory rooms and bedridden resident in an non-ambulatory room which poses an immediate health, safetyrisk to persons in care.
POC Due Date: 07/24/2024
Plan of Correction
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Licensee shall move all residents to their correspondant rooms to match what is on the fire clearance paperwork and facility sketch. Also, licensee shall inform responsible parties and family members of these changes. LPA will have to receive pictures of all residents in their correct room by POC due date
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having 2 non-working vehicles obstructing emergency exits which poses an immediate safety risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
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Licensee shall submit pictures of emergency exits free of obstruction by POC due date.
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: Valeria ConwayTELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/17/2024 04:53 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: BASSETT RESIDENTIAL CARE
FACILITY NUMBER: 197609923

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2024

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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Based on observation, the licensee did not comply with the section cited above by having a snap hook carabiner instead of a lock on kitchen and laudry cabinets which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
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Licensee shall change all snap hook carabiner and replace them with locks by POC due date. LPA will expect photos of such locks by POC due date.
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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria ConwayTELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2024
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BASSETT RESIDENTIAL CARE
FACILITY NUMBER: 197609923
VISIT DATE: 07/17/2024
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Continued from LIC 809

BEDROOMS: The residents’ bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate and clean bedding and linens such as sheets, pillowcases, and blankets. During today’s visit LPA observed Resident #1 (R1), a hospice patient, in room #4 unable to reposition in bed, after checking physician report for R1, it revealed that R1 is bedridden. R1 is being retained in a room that does not have bedridden fire clearance. Also, LPA observed two (2) non-ambulatory residents in ambulatory rooms and two (2) ambulatory residents in non-ambulatory room. LPA explained licensee that they all need to be rearrange. Also, licensee will have to communicate with family member and/or responsible parties of these changes.

BATHROOMS: The LPA observed all three (3) bathrooms were clean, properly supplied and had functional fixtures. LPA observed grab bars and non-skid mats in the bathroom. Residents have sufficient amounts of supplies for personal hygiene properly stored inaccessible to residents. Between 10:27 a.m. and 10:32 a.m., the hot water was measured in each bathroom during physical plant tour and measured within the required limit of 105-120 degrees Fahrenheit in all three (3) bathrooms.



COMMON AREAS: The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Laundry room is located right outside the hallway pass bedrooms #5 and #6. The LPA observed laundry detergent and supplies in cabinets above washer and dryer. Such cabinets were secured with a snap hooks carabiner instead of using a lock. LPA explained Licensee the importance to have these items stored inaccessible to residents with dementia. There is an attached locked garage accessible from the outside and the laundry room. LPA observed garage to store an extra fridge and freezer for perishable foods. Extra medical supplies and furniture was also observed in the garage.


Continued on LIC 809-C
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria ConwayTELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BASSETT RESIDENTIAL CARE
FACILITY NUMBER: 197609923
VISIT DATE: 07/17/2024
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Continued from LIC 809-C

SURROUNDING GROUNDS (Outdoors): LPA observed two (2) non-working vehicles that are obstructing the two (2) pathways leading to the emergency exits. Licensee agreed to have vehicles removed to prevent a potential hazard in case of an emergency. When checking emergency exits, LPA observed a back gate which was shut closed. LPA asked licensee to open the gate, however licensee was unable to so. Licensee agreed to ensure that side gate facing back alley is repaired so it can be opened and closed properly. There was an area with proper furniture for outdoor use in the area located outside of living room to the left of the property for residents to enjoy. There are no bodies of water on the premises.

RECORDS: Records review began at 2:00 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. Last emergency drill (Fire drill) was conducted on 07/02/2024.

MEDICATIONS: Medications review began at 3:12 p.m., medications are centrally stored and locked in a cabinet in the hallway; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medication log.

Per California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiencies are cited (Refer to LIC 9099-D). Exit Interview Conducted. Failure to correct the deficiencies may result in civil penalties. A Civil Penalty in the amount of $1,000 was assessed during today's visit. Appeal Rights Discussed. A Copy of Report Issued.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria ConwayTELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024
LIC809 (FAS) - (06/04)
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