197610017-3-11-2024-31-AS-GSAO-D39SDC-20240311134654

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610017
Report Date: 03/11/2024
Date Signed: 03/11/2024 01:47:46 PM

Document Has Been Signed on 03/11/2024 01:47 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	SHERWOOD FOREST SENIOR LIVING		FACILITY NUMBER:	197610017
ADMINISTRATOR:	GOHAR AKASHYAN		FACILITY TYPE:	740
ADDRESS:	8635 AMESTOY AVENUE		TELEPHONE:	(818) 626-8297
CITY:	SHERWOOD FOREST	STATE: CA	ZIP CODE:	91325
CAPACITY:	6	CENSUS: 6	DATE:	03/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Akashyan Gohar		TIME COMPLETED:	01:55 PM

NARRATIVE

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On 03/11/24 at 8:40AM, Licensing Program Analyst (LPA) Gina Saucedo, arrived to conduct an unannounced, annual inspection at the facility. Upon arrival, LPA Saucedo met with caregiver Svetlana Petrosayn and disclosed the purpose of the visit. Akashyan Gohar, the administrator was called and arrived about ten (10) minutes later.

LPA asked for the census, resident, and staff rosters.

A physical tour was conducted at 8:55 AM and observed the following:

The Kitchen area was toured, and LPA observed there to be sufficient seven (7) day supply of non-perishable foods and perishable food for all residents. The kitchen area was clean at the time of the tour. There is a telephone line on the counter in the kitchen on your left-hand side. There is extra, food in the kitchen pantries. The knives are at the top of the kitchen counter on your right-side locked and inaccessible to the residents. The chemicals are under the sink locked and inaccessible to the residents.

The medications are locked and inaccessible to the residents in the pantry area on the other side of the facility.

Outside/Backyard: The outside/backyard has furniture for the residents with proper seating. There is small shed that has been converted to a staff office where files are now kept. It is locked and inaccessible to the residents. There is another shed on the left-side where there is extra items for the residents. The facility does have a signal system. The facility does not have a pool/body of water. The outside/backyard can be accessed from the kitchen area.

LIC 809C-continued

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024

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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SHERWOOD FOREST SENIOR LIVING	FACILITY NUMBER: 197610017
	VISIT DATE: 03/11/2024

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The fire extinguisher is located against the wall on your left-hand side of the entrance of the facility. It is fully charged. The expiration date is 02/2025. There is another fire extinguisher located down the hallway in between the resident rooms. There is also a fire extinguisher located at the entrance of the kitchen on your right-hand side.

Bedrooms: There are five (5) bedrooms and two (2) full bathrooms. Four (4) bedrooms are single, occupied and (1) shared. There is no staff room. All bedrooms and bathrooms were toured and were properly furnished and have appropriate bedding, linens, toiletry, and lightning. The bathrooms have proper toiletry, grab bars and non-skid mats. The bathroom temperatures of the water are within regulations reading at 110–112-degree Fahrenheit.

The dining/living room area has enough seating for the residents and the staff. There is a fireplace that is covered and inaccessible to the residents. There are two (2) dining room areas with a television. The first aid kit is on the counter area of one (1) of the dining halls.

The house temperature is at 72-degree Fahrenheit.

There are several smoke detectors/carbon monoxides in the dining/living area that are operable.

Administrative: There is no annual fee that is due right now. The Insurance plan is dated as of 01/2025. At the entrance of the facility against the left-side of the facility there is a billboard with signs: Yes, Ombudsman, Disaster Plan, Resident Rule, Theft and Loss, Designee, House Rules, Mitigation Plan and Hospice waiver.

Let it be noted, there has been changes to the original facility sketch. There was no access to the garage that was originally in the facility sketch. It is now converted to a Junior ADU and has a white gate surrounded. The original facility sketch had a clearance for three (3) bedrooms now the facility shows five (5) bedrooms. A hallway door was also removed. There is currently no fire clearance or building permits.

An exit interview was conducted, citations were issued, and a copy of this report was given to the administrator.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/11/2024 01:47 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 S.RO, 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: 03/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on the observation and record review, the licensee did not comply with the section cited above in two out of two bedrooms (areas) persons which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/12/2024
	Plan of Correction
1 2 3 4	Administration/Licensee will need to contact the fire department to receive immediate fire clearance.

Type A

Section Cited

HSC

1569.32

Regulations

Any duly authorized officer, employee, or agent of the department may, upon presentation of proper identification, enter and inspect any place providing personal care, supervision, and services at any time, with or without advance notice, to secure compliance with, or to prevent a violation of, this chapter. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on the observation, interview and record review, the licensee did not comply with the section cited above in one out of one area (garage) which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/12/2024
	Plan of Correction
1 2 3 4	LPA will have to come back to have full access to the garage area.

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: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 03/11/2024 01:47 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 S.RO, 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: 03/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87208(a)

Plan of Operation

(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on the observation, interview and record review, the licensee did not comply with the section cited above in submitting an application for two areas/(bedrooms)/and converted garage (new facility sketch) which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/20/2024
	Plan of Correction
1 2 3 4	The licensee will submit a written declaration explaining the steps that they are going to take to complete the project.

Type B

Section Cited

CCR

87305(a)

Alterations to Existing Buildings or New Facilities

Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on the observation, interview and record review, the licensee did not comply with the section cited above in two out of two bedrooms (areas) /garage conversion which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/20/2024
	Plan of Correction
1 2 3 4	The licensee will submit a written declaration explaining the steps that they are going to take to complete the project.

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: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024

LIC809 (FAS) - (06/04)

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