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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610017
Report Date: 04/26/2023
Date Signed: 04/26/2023 10:17:29 AM


Document Has Been Signed on 04/26/2023 10:17 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:SHERWOOD FOREST SENIOR LIVINGFACILITY NUMBER:
197610017
ADMINISTRATOR:GOHAR AKASHYANFACILITY TYPE:
740
ADDRESS:8635 AMESTOY AVENUETELEPHONE:
(818) 626-8297
CITY:SHERWOOD FORESTSTATE: CAZIP CODE:
91325
CAPACITY:6CENSUS: 3DATE:
04/26/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Gohar AkashyanTIME COMPLETED:
10:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Abeye Duguma and Licensing Program Manager (LPM) Naira Margaryan conducted unannounced case management to the facility to follow up with recent request of fire clearance regarding the designation of the residents’ rooms due to recent changes made to the physical plant.

LPA and LPM met the Administrator and explained the purpose of this visit. Shortly after the fire inspector, Linsey Pellegrini arrived to the facility to conduct an inspection based on the fire clearance request submitted by the Licensee.

On 04/17/2023, Woodland Hills South Adult and Senior Care Regional office received a request of new fire clearance and copies of LIC 200 and two (02) facility sketches (previous and proposed).
Upon Departmental review of submitted documents, the following issues were noted.
As per original sketch submitted to CCL, there were three (03) shared residents’ bedrooms for total of six (06) residents. All three (03) bedrooms used for the residents were approved for non-ambulatory fire clearance and one of the rooms can be used for bedridden resident.
A new sketch submitted with the fire clearance request is showing two (02) shared room and three (03) private room. The total capacity of the facility is still six (06). Licensee is requesting five (05) non-ambulatory and one (01) bedridden fire clearance.

(CONT. on LIC 809-C)
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


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: SHERWOOD FOREST SENIOR LIVING
FACILITY NUMBER: 197610017
VISIT DATE: 04/26/2023
NARRATIVE
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The original sketch is showing attached garage and proposed sketch is not showing the existing garage. At the time of this visit it was observed that the garage is converted to permitted Junior Accessory Unit (ADU).

Based on review of both sketches, it was concluded that the Licensee altered the bedroom #3 to two (02) private rooms and one (01) of the room that used to be a storage is currently identified as another bedroom.

At the time of this visit at (8:30 AM) LPA Duguma and LPM Margaryan conducted a full inspection of physical plant and observed the following.

The Administrator was advised the following.

· Alteration to existing building without proper notification to the Community Care Licensing Department, is a violation of Section 87305 California Code of Regulation Title 22, Division 6, Chapter 8
· To protect residents’ personal rights, The Licensee did not furnish the department with written notification, explaining the steps that you should have taken during construction, to ensure that residents continued to be accorded safe, healthful, and comfortable accommodations…
During the inspection, Linsey Pellegrini inspected rooms and stated the following; facility needs permit for room #3 and the conversion of the additional rooms. The licensee needs to provide electrical permit for alarm switches in three (03) rooms.
Based on inspection, observation and record review, the following deficiencies were cited and recorded on LIC809D.
No other immediate health and safety hazard is noted during this visit.
Exit interview is conducted, and a copy of report was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/26/2023 10:17 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: SHERWOOD FOREST SENIOR LIVING
FACILITY NUMBER: 197610017

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/10/2023
Section Cited

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87305 (a) Prior to construction or alterations, all facilities shall obtain a building permit. (b) The licensing agency may require the facility to acquire a local building inspection where the agency determines that a suspected hazard to health and safety exists. This requirement is not met as evidenced by;
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The Licensee will submit a written statement explaining the steps that they are going to take to complete the project.
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Based on record review and observations, the Licensee did not ensure to obtain building permit prior to alteration of existing building.
One of the bedrooms was converted to two (02) bedrooms and a change of used from storage to bedroom. This poses a potential health and safety risk to residents in care.
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Type B
05/03/2023
Section Cited

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87468.1 Personal Rights of Residents in All Facilities.(a) Residents in all residential care facilities for the elderly shall have..the following personal rights: (2) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. This requirement is not met as evidenced by;
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The Licensee will review regulation and submit a written letter certifying that, moving forward, they will ensure to follow and adhere to CCR Title 22 87468.1 Personal Rights of Residents in All Facilities; The written letter must be sent to the LPA by the POC due date.

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Based on record review and observations, Licensee did not inform the department how they are going to ensure that during construction residents continued to be accorded safe, healthful, and comfortable accommodations...This poses a potential personal rights violation to residents in care.

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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: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023
LIC809 (FAS) - (06/04)
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