197609980-2-28-2024-29-AS-SURA-D2VVQS-20240228153849

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609980
Report Date: 02/28/2024
Date Signed: 02/28/2024 03:40:13 PM

Document Has Been Signed on 02/28/2024 03:40 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:	AMY'S PARADISE HOME OF ANGELS INC.		FACILITY NUMBER:	197609980
ADMINISTRATOR:	EMMA AVETISYAN		FACILITY TYPE:	740
ADDRESS:	11950 ROSCOE BLVD		TELEPHONE:	(310) 913-6161
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY:	6	CENSUS: 6	DATE:	02/28/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Emma Elazyan		TIME COMPLETED:	02:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual inspection. LPA Urena was greeted by staff and explained the reason for the visit. Staff called administrator Emma Avetisyan on the phone, and the LPA explained the reason for the visit. LPA communicated with Administrator via cell phone.

LPA Urena and staff conducted a tour of the inside and outside the facility to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature of 70 degrees. The LPA observed required postings throughout the common space.

KITCHEN: Knives are stored in a locked cabinet drawer. Kitchen appliances were in operable condition. The facility has enough supply of perishable and non-perishable food. The freezer and refrigerator are stocked with a variety of foods. The emergency food supply is adequate for six residents and two staff. The laundry room is equipped with a functioning washer and dryer. The room was locked at the time of inspection. One fire extinguishers were fully charged and were last serviced/purchased on 02/26/2024

BEDROOMS: Bedrooms were furnished appropriately with appropriate furnishings and sufficient lighting. Bedroom #1 had one bed without linens or blankets. The other linens are clean and in good condition. Extra linens are found stored in the linen closet located between bedrooms #1 and #2.

Continues on LIC 9099C...

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMY'S PARADISE HOME OF ANGELS INC.	FACILITY NUMBER: 197609980
	VISIT DATE: 02/28/2024

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BATHROOMS: Bathroom was clean, shower area was in clean condition with grab bars, and a non-skid mat available. Hand washing sign was displayed, and sufficient amounts of soap and paper products in the bathroom.

OUTDOOR AREA: Backyard has a covered outdoor area equipped with outdoor furniture for residents’ use. There were no bodies of water noted. The side gate is unlocked. The gate has an alarm system. Several items(empty food plastic canisters, plastic bags, monitor, non-operational refrigerator, and metal long pieces were observed, which need to be removed from the seating outdoor/backyard area.

RECORDS: Records review began at 11:00 a.m., Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. Five out of six residents' physicians reports(LIC 602) TB Test section 6. was incomplete and did not have date test give, read, type of TB test. Six out of six Personal Property and Valuables form(LIC 621) first page was not filled out. Five out of six residents' records were missing residents' or/residents' representative signatures on different required forms: Admission Agreements, Personal Rights, etc. Two out of six residents files did not have physician's orders for hospice/home health care.

The LPA reviewed the following documents:

- LIC9020 Client Roster
- Liability Insurance

Due to time constraints, the LPA will conduct a continuation inspection at a later date.
Facility staff representative signed today's report. A copy of the report was issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/28/2024 03:40 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: AMY'S PARADISE HOME OF ANGELS INC.	FACILITY NUMBER: 197609980
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.725(a)

Levels of Care

(a) A residential care facility for the elderly may permit incidental medical services to be provided through a home health agency, licensed pursuant to Chapter 8 (commencing with Section 1725), when all of the following conditions are met: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review,, the licensee did not comply with the section cited above in 2 out of six persons, did not have on file documenation of services provided by the Home Health/Hospice agency LVN/RN, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/04/2024
	Plan of Correction
1 2 3 4	Licensee will submit Plan of Correction with Care plans for two residents to the LPA by 03/04/2024.

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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024

LIC809 (FAS) - (06/04)

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