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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610031
Report Date: 04/29/2022
Date Signed: 04/30/2022 10:13:12 AM


Document Has Been Signed on 04/30/2022 10:13 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. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:CARMEL OAKS ASSISTED LIVINGFACILITY NUMBER:
197610031
ADMINISTRATOR:NIRVANA GHAEMIFACILITY TYPE:
740
ADDRESS:4607 LENNOX AVETELEPHONE:
(818) 277-1948
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91423
CAPACITY:6CENSUS: 6DATE:
04/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Nirvana GhaemiTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual visit at 11:35 a.m. This annual inspection had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Nirvana Ghaemi, and explained the reason for the visit.

The LPA, with the guidance of the Administrator, 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.

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. At 11:50 a.m., the LPA and the administrator observed the kitchen knives to be stored in an unlocked cabinet drawer to the left side of the stove

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 12:15 p.m., the LPA and the administrator observed in Room #6 one bottle of medication located in the left hand side of the closet. The bedroom #6 was unlocked and the closet dore was open.

RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. During the visit, the LPA did not observe signage in bathroom #2 pertaining to proper hand hygiene. Proper signage and paper towels were promptly displayed.

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.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2022
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: CARMEL OAKS ASSISTED LIVING
FACILITY NUMBER: 197610031
VISIT DATE: 04/29/2022
NARRATIVE
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The facility maintained a temperature of 73 degrees. All exits have functioning auditory devices; however, at the time of the visit, they front and rear door leading to the back yard were turned off. The LPA observed the required postings in the common 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.

RECORD REVIEW: During today's visit, at arrival at 11:35 a.m., S1 was observed to be working at this facility. During todays’ visit at 12:30 p.m., it was observed that Staff #1 (S1) was not associated to the facility, and a file for S1 was not available. Per the interview with S1, S1 stated that they had been working at the facility for one week. A civil penalty was issued on 04/29/2022, noting that S1 could not return to the facility until the background check and association to the facility was complete. The LPA reviewed the Caregiver Background Check System during today’s visit and observed that S1 was not associated to this facility. Per the staff schedule, S1 worked on 12/17/2021, 12/18/2021, and today, 12/21/2021.

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 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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022
LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 04/30/2022 10:13 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. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: CARMEL OAKS ASSISTED LIVING
FACILITY NUMBER: 197610031

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2022

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
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Based on observation, the licensee did not comply with the section cited above as knives were accessible in a kitchen drawer, which poses an immediate health and safety risk to residents in care.
POC Due Date: 04/29/2022
Plan of Correction
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The Administrator has agreed to do the following:
1. The knives were locked. Plan of Correction met.
Type A
Section Cited
CCR
87309(b)
Storage Space
(b) Medicines shall be stored as specified in Section 87465(c) and separately from other items specified in (a) above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above, as one bottle (1), of personal medication was kept unlocked and accessible in Room #6, which poses an immediate health and safety risk to residents in care.
POC Due Date: 04/29/2022
Plan of Correction
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The Administrator has agreed to do the following:
1. The medication was removed to a secure location. Plan of Correction met.

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 PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 04/30/2022 10:13 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. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: CARMEL OAKS ASSISTED LIVING
FACILITY NUMBER: 197610031

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)(13)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above as one (1) out of six (6) staff didnot have a criminal record cleareance, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2022
Plan of Correction
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The Administrator has agreed to the following:
1. The Administrator has agreed to do the following: Obtain verification from the Caregiver Background Check Bureau that S1 is cleared prior to working at the facility.
2. S1 will not work at the facility until the exemption is approved. by 5/6/2022.

Type A
Section Cited
CCR
87412(a)(13)(A)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (A) A signed statement regarding their criminal record history as required by Section 87355(d).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in as one(1) out of six (6) staff didnot have staff file and a signed statement regarding their criminal record history on file, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2022
Plan of Correction
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1. The Administrator has agreed to do the following: Obtain verification from the Caregiver Background Check Bureau that S1 is cleared prior to working at the facility.
2. S1 will not work at the facility until the exemption is approved. by 5/6/2022.

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 PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 04/30/2022 10:13 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. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: CARMEL OAKS ASSISTED LIVING
FACILITY NUMBER: 197610031

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2022

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
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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: 05/02/2022
Plan of Correction
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The Administrator has agreed to do the following:
1. Obtain additional food. Submit proof (ie. receipt, photos) to the Department by 5/02/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6