<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609934
Report Date: 01/30/2025
Date Signed: 01/30/2025 04:38:22 PM

Document Has Been Signed on 01/30/2025 04:38 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:KAREN'S HOME FOR SENIORS, INC.FACILITY NUMBER:
197609934
ADMINISTRATOR/
DIRECTOR:		ZINKOFSKY, CLARITAFACILITY TYPE:
740
ADDRESS:16822 ADDISON STREETTELEPHONE:
(818) 886-8360
CITY:ENCINOSTATE: CAZIP CODE:
91436
CAPACITY: 6CENSUS: 5DATE:
01/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Brandon ZinkofskyTIME VISIT/
INSPECTION COMPLETED:
04:40 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
At 9:45 a.m. on 01/30/25, Licensing Program Analysts (LPA) Nicholas Reed and Nadia Shahbazian conducted an unannounced complaint visit. LPA met with staff and later the administrators and disclosed the reason for the visit.

The facility was last visited on 03/16/2024 for an annual visit. It is a single story building with six (06) bedrooms, two (02) bathrooms, kitchen, laundry area, common areas, and outdoor space. It has an approved fire clearance for six (06) nonambulatory residents. Approved hospice waivers for six (06).

LPAs observed a maintained front yard with an unlocked entry gate. A screening station at the front contained sanitizer, a digital thermometer, and a visitor log. Postings at the front included COVID precautions, facility license, confidential complaints contacts, ombudsman contacts, emergency disaster plan, rights of resident councils, personal rights, and the facility sketch. Cameras were observed in the common areas and exterior areas.

Walls, floors, windows, and screens were clean and in good repair. The living rooms contained a television, a piano, and furniture in good repair. Confidential files were locked in a cabinet near the television.

The facility has six (06) bedrooms. Bedroom #6 is designated as a staff room. The staff room was unlocked and free of hazards. All bedrooms contained a chair, lamp, nightstand, a dresser, and a bed with adequate bedding. All furnishings were clean and in good condition. All rooms with hospital beds had wheels in the locked position. Half bed rails were observed in Bedroom #1 and Bedroom #2. Full bed rails were observed in Bedroom #3 and Bedroom #5.

The facility has two (02) bathrooms. One (01) bathroom is private to Bedrooms #5, and one (01) is shared. All bathrooms contained liquid soap, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2025
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 6
Document Has Been Signed on 01/30/2025 04:38 PM - It Cannot Be Edited


Created By: Nicholas Reed On 01/30/2025 at 04:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: KAREN'S HOME FOR SENIORS, INC.
FACILITY NUMBER: 197609934

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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 due to the accessible cleaning chemicals in the shared bathroom which pose an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2025
Plan of Correction
1
2
3
4
Licensee to conduct an in-service training for all staff and submit proof of correction by the POC due date.
Type A
Section Cited
CCR
87309(b)
Storage Space and Access
(b) Residents may have access to items specified in subsection (a) for personal use unless there is documentation, as specified in Section 87457, Pre-Admission Appraisal or Section 87463, Reappraisals, that indicates the resident's or other residents’ safety would be at risk if allowed access.

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 three (03) accessible shaving razors which poses an immediate health, safety or personal rights risk to persons in care with dementia.
POC Due Date: 02/03/2025
Plan of Correction
1
2
3
4
Licensee to conduct an in-service training for all staff and submit proof of correction by the 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:Naira Margaryan
LICENSING EVALUATOR NAME:Nicholas Reed
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2025


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 01/30/2025 04:38 PM - It Cannot Be Edited


Created By: Nicholas Reed On 01/30/2025 at 04:06 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: KAREN'S HOME FOR SENIORS, INC.
FACILITY NUMBER: 197609934

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(f)
87411 Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall... be in good health verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.

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 one (01_ staff without a tuberculosis test or chest X-ray which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2025
Plan of Correction
1
2
3
4
Licensee has instructed the staff without a TB test to obtain test results prior to returning to work.
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:Naira Margaryan
LICENSING EVALUATOR NAME:Nicholas Reed
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: KAREN'S HOME FOR SENIORS, INC.
FACILITY NUMBER: 197609934
VISIT DATE: 01/30/2025
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
26
27
28
29
30
31
32
At 10:05 a.m., LPAs observed hazardous cleaning supplies below the sink in the shared bathroom were accessible. At 10:10 a.m. LPAs observed two (02) shaving razors on the nightstand in Bedroom #2. LPAs also saw an accessible shaving razor in the private bathroom to Bedroom #5 at approximately 10:15 a.m. A deficiency is issued for accessible sharp objects and cleaning supplies on the corresponding LIC 809-D page. At approximately 10:20 a.m. LPAs measured the water temperature in the shared bathroom to be 117.5 degrees Fahrenheit. At 10:25 a.m., dual purpose smoke and carbon monoxide detectors were tested and operational. At 10:30 a.m. LPAs measured the room temperature to be 69 degrees Fahrenheit. Around 10:35 a.m., LPAs observed a smoke detector in the hallway near Bedroom #1 to be operational but not secure to the wall. At the same time, LPAs observed the two hallway air vents were in need of light cleaning. Also, blinds in the kitchen needed light cleaning. These Technical Violations are noted on corresponding LIC 9102-TV pages.

LPAs called out from the house telephone at 10:40 a.m. The phone was deemed operational. LPAs observed an adequate supply of perishable and non-perishable foods in the kitchen. Appliances were in good condition. Sharps and cleaning solutions were locked under the sink and counter top. Medications, emergency lighting, and a complete first aid kit were locked above the counter top. At approximately 10:50 a.m. a fully charged fire extinguisher was observed in the kitchen. It was last inspected on 01/21/25. The stove surface was clean. A washing machine and dryer were located in the laundry area adjacent to the kitchen. Both were in working order. Detergents and cleaning supplies were locked near the appliances.

LPAs observed a patio area in the rear of the facility. The patios contained a shaded area with chairs. The back yard was maintained. The garage and a storage shed were locked and inaccessible.

All emergency exit paths were free from obstructions. Three (03) out of three (03) exit gates were unlocked. Two (02) out of two (02) auditory alarms were turned on and functioning.

At 11:30 a.m. LPAs reviewed staff and resident files. Review of staff files revealed Staff #1 (S1) did not have a tuberculosis test on file. A deficiency is cited on the corresponding LIC 809-D page for S1 not having a tuberculosis test prior to employment. Four (04) out of five (05) resident files needed Needs and Service plans updated, so a Technical Violation is assessed for this update on the corresponding LIC 9102-TV page.

Exit interview conducted. Appeal rights discussed. Copy of report provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC809 (FAS) - (06/04)
Page: 6 of 6