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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609934
Report Date: 03/16/2024
Date Signed: 03/27/2024 09:11:37 AM


Document Has Been Signed on 03/27/2024 09:11 AM - 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., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:KAREN'S HOME FOR SENIORS, INC.FACILITY NUMBER:
197609934
ADMINISTRATOR:ZINKOFSKY, CLARITAFACILITY TYPE:
740
ADDRESS:16822 ADDISON STREETTELEPHONE:
(818) 886-8360
CITY:ENCINOSTATE: CAZIP CODE:
91436
CAPACITY:6CENSUS: 6DATE:
03/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Brandon ZinkofskyTIME COMPLETED:
02:35 PM
NARRATIVE
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Licensing Program Analyst (LPA), Tihesha Smith conducted an unannounced annual iinspection at this facility at 10:10 am. LPA Smith contacted Licensee (Martin Zinkofsky) by telephone and requested to have staff open door. Licensee stated will have staff open door. LPA was greeted by staff and disclosed the purpose of the visit. The administrator was not present at the facility upon LPA Smith arrival.

LPA conducted a tour of the physical plant at approximately 10:20 am to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Common areas were observed for the ability to safely serve the needs residents. These included the kitchen/dining room combination, living room and family room. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to be furnished appropriately with adequate seating for residents.

LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The
kitchen food supply was observed and sufficient for the six (6) residents currently residing there. Two (2) days of perishable food observed. The freezer is stocked with meats and frozen vegetables. Sharps are stored in locked kitchen drawer. The resident medications and first aid kit stored in locked cabinet next to refrigerator and observed to be locked and inaccessible to residents. There is one (1) fire extinguisher attached to kitchen wall and observed to be charged.

Laundry room is located in walk through next to kitchen The appliances observed to be functional. Toxins stored in locked floor cabinet next to dryer and was observed to be locked and inaccessible to residents.
The facility has a total of six (6) bedrooms and two (2) bathrooms: there is one (1) shared and four (4) private bedrooms for residents and one (1) bedroom for staff.

(Cont to 809C)

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha SmithTELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2024
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: KAREN'S HOME FOR SENIORS, INC.
FACILITY NUMBER: 197609934
VISIT DATE: 03/16/2024
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(Cont. from 809)
The resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for
each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed a supply of linens in hall closet.

Each bathroom had the following items available: hand soap, paper towels, and trash cans. The hot water temperature was measured for in bathrooms to ensure it within the required range for residents’ comfort and safety. The water temperature range was measured at 115 and 119.5-degrees Fahrenheit for main bathroom shower.

There is no body of water in the facility.
Backyard has the following: (1) one patio table, with seating. Patio furniture observed to be in good repair.

Administrator arrived at approximately 10:55 am and unlocked detached garage for LPA to observe. Detached Garage: Used for storage of equipment and furniture.

Storage shed used for storage in backyard observed to be locked and inaccessible to residents.

Smoke detectors/carbon monoxide detector were tested and operable at time of visit.

Facility grounds were free of hazards. There were no immediate health and safety hazard observed during the day of inspection.

At approximately 10:50 am, LPA reviewed files for the six (6) residents. Resident files included medical assessments, Appraisal/Needs and services plans, admissions agreements. One (1) of six (6) resident files had an incomplete physician’s report in addition to not having physician's signature. Staff documents reviewed for two (2) staff. Staff files had the appropriate training's and current CPR training.

Technical advisory for frayed back screendoor. Deficiencies cited on 809D

Exit Interview Conducted / A Copy of the Report Issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha SmithTELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/27/2024 09:11 AM - 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., STE. 250
WOODLAND HILLS, CA 91364


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

FACILITY NUMBER: 197609934

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 03/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

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 out of one record (missing completed physcians report which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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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: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha SmithTELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2024
LIC809 (FAS) - (06/04)
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