197609995-5-13-2021-29-AS-ASMH-C2YSEQ-20210513134906

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609995
Report Date: 05/13/2021
Date Signed: 05/13/2021 01:49:40 PM

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:	HEART OF HOME SENIOR LIVING		FACILITY NUMBER:	197609995
ADMINISTRATOR:	MOVSESIAN, KAJO		FACILITY TYPE:	740
ADDRESS:	6425 NAGLE AVE		TELEPHONE:	(747) 247-2365
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91401
CAPACITY:	6	CENSUS: 5	DATE:	05/13/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Kajo Movsesian		TIME COMPLETED:	02:00 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Ashley Smith and Emily Peraldi arrived at the facility unannounced to conduct a required annual visit at 10:30am. When the LPAs arrived, there was one staff and five residents present. Administrator Kajo Movsesian arrived around 10:45am.

The LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

OUTDOOR SPACE: The LPAs observed the backyard, which has a covered outdoor area for resident use. There is a gate on the side of the house that is single latched; however, at 11:01am, the latch was padlocked. The LPAs informed the Administrator that this had to be removed.

KITCHEN: The LPAs observed the kitchen/dining area at 12pm. Knives are stored in a locked cabinet in the kitchen. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 12:05pm, the LPAs observed over-the-counter milk of magnesia in the refrigerator. At 12:07pm, the LPAs observed Lysol on the counter. The staff removed these items upon observation.

BEDROOMS: The LPAs observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid mat. At 12:17pm, the LPA observed that the bathroom in the common hallway was not stocked with paper towels. Technical violation was issued for improper infection control protocol.

INFECTION CONTROL: During today’s visit, the LPAs spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station.

CONT 809-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HEART OF HOME SENIOR LIVING	FACILITY NUMBER: 197609995
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/13/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. 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, as there were cleaning supplies and over-the-counter medications accessible, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/13/2021
	Plan of Correction
1 2 3 4	The Administrator has agreed to do the following: 1. The items were removed upon observation. Plan of Correction met.

Type A

Section Cited

CCR

87468.1(a)(6)

87468.1(a)(6) Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. 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, as the self-latching gate which exits to the front was padlocked, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/13/2021
	Plan of Correction
1 2 3 4	The Administrator has agreed to do the following: 1. The lock has been removed. Plan of Correction met.

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HEART OF HOME SENIOR LIVING	FACILITY NUMBER: 197609995
	VISIT DATE: 05/13/2021

NARRATIVE

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The LPAs observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate.

The following recommendations were made:

- Documenting temperatures for staff and residents

- Testing Protocol, to ensure that 25% of staff are being tested weekly
- Appropriate signage to remind staff and residents of cough etiquette, visitation policies and procedures, hand hygiene, etc.
- Posting Provider Information Notices (PINs) and educating staff, residents, and families on changing policies and procedures from the Department
- Identifying and on boarding reserve staff as needed

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021

LIC809 (FAS) - (06/04)

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