197610031-5-6-2025-29-AS-ZCHN-DGF6YQ-20250506211355

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610031
Report Date: 05/06/2025
Date Signed: 05/06/2025 09:55:18 PM

Document Has Been Signed on 05/06/2025 09:55 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	CARMEL OAKS ASSISTED LIVING		FACILITY NUMBER:	197610031
ADMINISTRATOR/ DIRECTOR:	NIRVANA GHAEMI		FACILITY TYPE:	740
ADDRESS:	4607 LENNOX AVE		TELEPHONE:	(818) 277-1948
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91423
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	05/06/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:30 AM
MET WITH:	Nirvana Ghsemi		TIME VISIT/ INSPECTION COMPLETED:	05:15 PM

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Licensing Program Analyst (LPA) Zabel Chochian arrived at the facility today to conduct a required annual visit. The LPA met with Administrator/Operator Nirvana Ghaemi, and explained the reason for the visit.

The LPA, and the Administrator toured the physical plant areas at approximately 10:40 a.m. inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Fire extinguisher last serviced 05/16/2024.

BEDROOMS: The resident bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are three bedrooms for resident use; room#3 and room #4 are designated staff room. Rooms #1, #2, #5 and #6 are designated resident rooms. RESTROOMS: Residents’ restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Proper hygiene products and paper products are available for use. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable food and non-perishable food; knives, sharps observed stored in a locked cabinet drawer; clean supplies also observed locked under kitchen sink cabinet.

The facility maintained a temperature of 75 degrees. All exits have functioning auditory devices. Required postings observed in the kitchen and hallway area.

The backyard has a covered outdoor area equipped with furniture for resident use. The side gate door is self-latching. There were no bodies of water noted. The garage is detached from the home and kept locked.

Laundry machine and detergents observed in the locked garage. (Continue to LIC809c).

Desaree Perera	TELEPHONE: (818) 596-4347
Zabel Chochian	TELEPHONE: (818) 419-5440
	DATE: 05/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: CARMEL OAKS ASSISTED LIVING	FACILITY NUMBER: 197610031
	VISIT DATE: 05/06/2025

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RESIDENTS' records review began at 11:30 a.m., records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order.

STAFF records review began at 12:45 p.m., records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 2:30 p.m. Medications are centrally stored and locked in a cabinet in staff room #4. Medications were labeled and checked for expiration dates. Medications are properly documented on the Centrally Stored Medication & Destruction Record (LIC 622)..Two residents’ medications were audited and found to be in order. All medications were logged, contained all required fields. Administrator did not have a PRN Authorization letter on file for resident #2 and resident #3.

INFECTION CONTROL: Staff are following facility's infection control plan; maintaining cleanliness and disinfecting/sanitizing facility daily. .

The LPA requested administrator to submit an updated LIC500 Personnel Report and current liability insurance be sent to CCL by 05/9/2025.

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 was conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/06/2025 09:55 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CARMEL OAKS ASSISTED LIVING	FACILITY NUMBER: 197610031
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87465(d)

Incidental Medical and Dental Care Services

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, observation and interview, the licensee did not comply with the section cited above. No record of the PRN Authorization letter on file for Resident #2 and Resident #3. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/09/2025
	Plan of Correction
1 2 3 4	Administrator agreed to obtain the PRN authorization letter for Resident #2 and Resident #3 from the physician and maintain on file. Submit copy of the PRN authorization letters obtained by due date 5/9/2025.

Type B

Section Cited

CCR

87633(b)

Hospice Care for Terminally Ill Residents

(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above. Resident #6 was put on hospcie since 11/12/2024; no care plan observed on file. Administrator confirmed with the hospice agency during todays visit that the resident is no longer on hospice due to issues with the insurance. This poses/posed a potential health, safety risk to persons in care.
	POC Due Date: 05/09/2025
	Plan of Correction
1 2 3 4	Administrator agreed to review hospice waiver and all requirements and submit a self-certified letter by 05/09/2025 acknowledging everything was reviewed and will ensure compliance with all hospice requirements in the future.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Desaree Perera	TELEPHONE: (818) 596-4347
Zabel Chochian	TELEPHONE: (818) 419-5440
	DATE: 05/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025

LIC809 (FAS) - (06/04)

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