197610031-5-14-2021-29-AS-ASMH-C2ZQH3-20210514121028

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610031
Report Date: 05/14/2021
Date Signed: 05/14/2021 12:11:04 PM

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:	NIRVANA GHAEMI		FACILITY TYPE:	740
ADDRESS:	4607 LENNOX AVE		TELEPHONE:	(818) 277-1948
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91423
CAPACITY:	6	CENSUS: 4	DATE:	05/14/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Nirvana Ghaemi		TIME COMPLETED:	12:20 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 Analysts (LPAs) Ashley Smith and Sandra Urena arrived at the facility unannounced to conduct a required annual visit 9:35am. This annual had a specific emphasis on infection control practices and procedures. The LPAs met with Administrator Nirvana Ghaemi and explained the reason for the visit.

The LPAs, with the guidance of staff, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

BEDROOMS: The LPAs observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are six bedrooms for resident use; however, Room #4 and Room #6 are currently occupied as staff rooms. At 9:55am, the LPAs observed Room #3. There were accessible medications observed in the room.

RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. During the visit, the LPAs did not observe signage in any of the bathrooms pertaining to proper hand hygiene. In addition, at 9:59am, the LPAs observed accessible disinfectant in the bathroom. This item was properly secured upon observation.

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. The facility maintained a temperature of 73 degrees. All exits have functioning auditory devices; however, at the time of the visit, they were turned off. The LPAs observed the required postings in the common area; however, the facility did not have the Department complaint poster.

The backyard has a covered outdoor area equipped with furniture for resident use. The side gate door is self-latching. Although it was not locked during today’s visit, the LPAs observed a padlock by the door. The Administrator was reminded that the side gate cannot be locked. There were no bodies of water noted. The garage is detached from the home.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2021

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 11

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: 05/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(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, the licensee did not comply with the section cited above, as there was accessible disinfectant observed in the bathroom, which poses an immediate health and safety risk to residents in care.
	POC Due Date: 05/14/2021
	Plan of Correction
1 2 3 4	The Administrator has agreed to do the following: 1. The disinfectant was removed upon observation. Plan of Correction met.

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above, as all facility medications were kepted unlocked and accessible in Room #3, which poses an immediate health and safety risk to residents in care.
	POC Due Date: 05/17/2021
	Plan of Correction
1 2 3 4	The Administrator has agreed to do the following: 1. Remove the medications to a secure location. 2. Review Regulation 87465 and send a self-certification note when it is complete. Send by 5/17/2021.

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: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2021

LIC809 (FAS) - (06/04)

Page: 2 of 11

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: 05/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(26)

General Food Service Requirements

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. 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 facility did not have a one week supply of nonperishable food, which poses a potential health and safety risk to residents in care.
	POC Due Date: 05/17/2021
	Plan of Correction
1 2 3 4	The Administrator has agreed to do the following: 1. Obtain additional food. Submit proof (ie. receipt, photos) to the Department by 5/17/2021.

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: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2021

LIC809 (FAS) - (06/04)

Page: 3 of 11

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: 05/14/2021

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
26
27
28
29
30
31
32

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable food; however, the facility does not have a sufficient seven day supply of non-perishable food. In addition, the LPAs observed produce in the fridge and freezer that were left open and improperly packaged.

INFECTION CONTROL: During today’s visit, the LPAs spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPAs observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate.

The following recommendations were made:
- Appropriate signage to remind staff and residents of cough etiquette, visitation policies and procedures, hand hygiene, etc.
- Posting Provider Information Notices (PINs) and educating staff, residents, and families on changing policies and procedures from the Department

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

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2021

LIC809 (FAS) - (06/04)

Page: 11 of 11