197610002-8-16-2024-29-AS-CYEE-D884B4-20240816185652

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610002
Report Date: 08/16/2024
Date Signed: 08/16/2024 06:57:04 PM

Document Has Been Signed on 08/16/2024 06:57 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:	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: 6	DATE:	08/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Arman Sargsyan, Administrator		TIME COMPLETED:	07:00 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 he arrived at 11:51 am to conduct the visit. Jasmine Sargsyan, Licensee arrived 11:56 am to also participate in the visit. 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. All 12 domains of the CARE Inspection Tool was reviewed on today's visit. Also reviewed on today's visit were all 6 resident files and all 7 staff files. The following were observed on today's visit: the living room, dining room and kitchen were furnished and equipped with the appropriate furniture and equipment for its designated use and for the licensed capacity. The fire place in the front room was observed with a fire screen. All the bedrooms were equipped with 2 each of the following: 2 hospital beds, 2 chairs, 2 night stands, 2 lamps, 2 dressers in bedroom #1, 1 shared dresser in bedroom # 2 and bedroom #3 and a shared closet in all the bedrooms. The common bathroom by the front room has a toilet, sink and a tub with a shower. Grab bars, a shower chair and a non-skid mat was observed. Water temperature was tested and read 113.6 degrees Fahrenheit. The common bathroom located between bedroom #2 and #3 has a walk in shower, a toilet, and a sink

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024

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

FACILITY NAME: JASMINE	FACILITY NUMBER: 197610002
	VISIT DATE: 08/16/2024

NARRATIVE

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Grab bars, a non-skid mat and a shower chair was observed. Water temperature was tested and it read 113.7 degrees Fahrenheit.
the linen closet located in the bedroom hall was observed with extra linens, towels and blankets.
medications are stored in a locked cabinet in the living room
The laundry room located by the kitchen was observed with a washer and dryer. Cleaning solutions and disinfectants are locked in a cabinet in the laundry room
the only fire extinguisher purchased on 7/10/24 is located on the wall between the kitchen and laundry room.
Sufficient perishable foods for a minimum of 2 days and non-perishable foods for a minimum of 7 days were observed.
The auditory devices on the front door, the sliding glass door in the living room and bedroom #3 were all operational.
Hygiene products were observed stored in locked cabinets the laundry room and in the common bathroom.
The facility has current liability insurance with limits meeting Title 22 requirements until September 2024.
First aid kit with a pair of scissors, tweezer, thermometer and a first aid manual was observed.
The interconnected smoke detectors and a smoke/carbon monoxide detector located in the bedroom hallway were tested and they were operational.
Required posters were observed.
Per tour of the backyard, a gazebo with tables and chairs were observed. 3 storage sheds were also observed.
the trash cans stored in the front yard was observed to be in good condition and tightly sealed.
The front and backyard were observed to be clean.

Deficiencies were cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Civil penalties were assessed.

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

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 08/16/2024 06:57 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: JASMINE	FACILITY NUMBER: 197610002
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(1)

87355 Criminal Record Clearance(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or 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 as it was observed that Liana Khanoyan, staff in training, was present in the facility without having obtained a criminal record clearance prior to being present at the facility on the following days - 8/9/24, 8/12/24 - 8/14 and 8/16/24 which poses an immediate health, safety or personal rights risk to persons in care. Civil Penalties were assessed.
	POC Due Date: 08/19/2024
	Plan of Correction
1 2 3 4	Licensee will submit a plan of action as to how the facility will ensure that any employees, volunteers or any individual(s) who is required to obtain a criminal record clearane prior to being present at the facility by 8/19/24. Staff was asked to leave the facility during the 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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024

LIC809 (FAS) - (06/04)

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