197610002-8-3-2023-29-AS-CYEE-CUC36Y-20230802175904

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610002
Report Date: 08/02/2023
Date Signed: 08/03/2023 08:41:54 AM

Document Has Been Signed on 08/03/2023 08:41 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	JASMINE		FACILITY NUMBER:	197610002
ADMINISTRATOR:	SARGSYAN, ARMAN		FACILITY TYPE:	740
ADDRESS:	7331 KATHERINE AVE		TELEPHONE:	(818) 785-4230
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY:	6	CENSUS: 4	DATE:	08/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Arman Sargsyan, Administrator		TIME COMPLETED:	06:10 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	Licensing Program Analyst(LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool. LPA Yee was let into the facility by Gayane Yeghiazaryan, Staff. Arman Sargsyan, Administrator was contacted by telephone and arrived at around 10:40 am to conduct the visit. Also participating in today's visit was Jasmine Sargsyan, Licensee. The facility is a single storey home consisting of a living room, dining room, kitchen, 3 bedrooms, 3 full bathrooms and a attached garage that was converted into a office/living quarters. The facility is fire cleared for 6 non-ambulatory residents. The following were observed on today's visit: the living room and dining room were clean and had the appropriate furnishing and seating for 6 residents. Centrally stored medications are stored in the locked cupboard located in the living room. Staff medications and vitamins were observed stored in 2 unlocked drawers located in living room. the kitchen was clean and all appliances were operational. Sufficient perishable and non-perishable foods were observed. Recommendation was made to increase non-perishables foods to include working staff during an emergency. Knives were stored in a locked black box. adjacent to the kitchen is the laundry room equipped with a washer and dryer. Also located in the laundry room is a locked cabinet used to store the cleaning solutions Bedroom #1 (double occupancy) has 2 hospital beds with full bed rails, 2 night stands, 2 chairs, 2 lamps but no dressers and a shared closet. Both occupants are on hospice. Oxygen in use on today's visit. Oxygen in use posted on the door. Per information provided, the local fire department was not notified in writing. Bedroom #2 (double occupancy) has 2 hospital beds with full bed rails, 2 chairs, 2 night stands, 2 lamps, a shared closet and no dressers. One occupant on hospice.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: JASMINE	FACILITY NUMBER: 197610002
	VISIT DATE: 08/02/2023

NARRATIVE

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Bedroom #3 (double occupancy) currently vacant, has one hospital bed, 2 night stands, 2 chairs, 2 lamps and a shared closet. Shared drawer observed in the closet. Facility supplies stored in the resident closet needs to be relocated.
extra bed linens, blankets, towels and comforters were observed in the linen closet
the common bathroom located to the left of the entry way to the resident rooms has a tub with a shower, a sink. Grab bar and a non-skid mat was observed. The toilet was enclosed with metal frame, to assist with mobility. Water temperature was tested and read 117.3 degree Fahrenheit.
the second common bathroom located between bedroom #2 and bedroom #3 has a shower with grab bars, a shower chair, non-skit mat and a toilet with a metal frame. Water temperature tested read 119.2 degrees Fahrenheit.
The only fire extinguisher, purchased on 7/26/23, is located in the kitchen and expires on 7/25/24
First Aid kit was reviewed and had a tweezer and scissors. A separate thermometer and First aid manual was observed.
The required posters were observed.
The interconnected smoke detectors located in resident bedrooms and hallway were tested and were operational. The only carbon monoxide detector is located in the bedroom hall and is operational.
The auditory devices installed on the back glass doors were operational.
There were no bodies of water observed.
The wood left on the front yard needs to be discarded.
The backyard has a covered gazebo with a coffee table and chairs.
The metal beds and wheel chairs stored in the back yard by bedroom #3, need to be discarded or stored. The large piece of metal stored along the left side of the home needs to be stored or discarded.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 18.

Exit interview was conducted, Appeals Rights were discussed and a copy was provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/03/2023 08:41 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: JASMINE	FACILITY NUMBER: 197610002
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(5)(A)

Postural Supports

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. 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 1 out of 4 beds observed. Resident #3's hospital bed had full bed rails and this poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/09/2023
	Plan of Correction
1 2 3 4	LIcensee will remove the full bed rails off of Resident #3's bed. A half bedrail may be used. Provide evidience of removal by 8/9/23 Note: corrected at the time of the visit

Type B

Section Cited

CCR

87618(b)(3)(A)

Oxygen Administration - Gas and Liquid

(3) Ensuring that the use of oxygen equipment meets the following requirements: (A) A report shall be made in writing to the local fire jurisdiction that oxygen is in use at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview with the Licensee, Resident #1 was admitted to the facility on 7/2/23 and uses oxygen and the licensee did not comply with the section cited above in 1 out of 1 count by failing to report the use of oxygen at the faciity, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/09/2023
	Plan of Correction
1 2 3 4	The Licensee will submit written notification to the Fire Dept by the POC date and inform CCLD when completed. NOTE: CORRECTED AT TIME OF VISIT.

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: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/03/2023 08:41 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: JASMINE	FACILITY NUMBER: 197610002
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

(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
1 2 3 4	Based on observation, staff medications and vitamins were stored in 2 separate unlocked drawers located in the living room. The licensee did not comply with the section cited above in 2 out of 2 counts which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/03/2023
	Plan of Correction
1 2 3 4	The Licensee will ensure that staff do not store personal medications in unlocked drawers that are accessible to residents in care. Licensee will re-locate all staff medications and vitamins to an area that is inaccessible to the residents in care. Licensee will provide training to staff in the storage of medications and poisons. Licensee will provide LPA Yee with a copy of the inservice training log by 8/9/23. Medications were relocated at time of visit.

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/03/2023 08:41 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: JASMINE	FACILITY NUMBER: 197610002
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(a)(3)(E)

Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents,staff, and others who may reside in the facility. The following provisions shall apply:(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of:(E) Portable or permanent closets and drawer space in the bedrooms for clothing and personal belongings. A minimum of eight (8) cubic feet (.743 cubic meters) of drawer space per resident shall be provided. 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 Bedroom #2 and Bedroom #3 did not have any dressers which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/09/2023
	Plan of Correction
1 2 3 4	Licensee will purchase dressers for residents in bedroom #2 and #3 that meet the requirements under Title 22. Provide evidence that the correction has been made by 8/9/23 - Corrected at time of visit

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: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

LIC809 (FAS) - (06/04)

Page: 5 of 6

Document Has Been Signed on 08/03/2023 08:41 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: JASMINE	FACILITY NUMBER: 197610002
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors 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 front yard and backyard requires general maintenance. The wood in the front yard needs to be discarded, the beds and potty chairs stored in the backyard by bedroom 3 needs to be stored/discarded and the large metal sheet stored along the left side of the home needs to be stored which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/16/2023
	Plan of Correction
1 2 3 4	Licensee will perform general maintenance to store unused items and discard unwanted items located in the front yard, backyard and along the left side of the home by 8/9/23

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

LIC809 (FAS) - (06/04)

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