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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610031
Report Date: 01/11/2023
Date Signed: 01/11/2023 03:05:02 PM


Document Has Been Signed on 01/11/2023 03:05 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 LIVINGFACILITY NUMBER:
197610031
ADMINISTRATOR:NIRVANA GHAEMIFACILITY TYPE:
740
ADDRESS:4607 LENNOX AVETELEPHONE:
(818) 277-1948
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91423
CAPACITY:6CENSUS: 6DATE:
01/11/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Nirvana GhaemiTIME COMPLETED:
02:00 PM
NARRATIVE
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On 01/11/2023, Licensing program Analysts (LPAs) Sandra Urena, and Ashley Smith conducted an unannounced Case Management-Deficiencies inspection visit at 09:20 a.m. due to deficiencies observed during the investigation of Complaint Control # 29-AS-20230103142731. The LPAs met with Administrator Nirvana Ghaemi, and explained the reason for the visit.

At 9:25 a.m. the LPAs conducted a brief tour of the physical plant. From 9:30 a.m. to 10:21 a.m. LPAs conducted resident interviews, and from 10:30 a.m. to 11:08 a.m. LPA’s conducted staff interviews. Record review was done from 11:10 a.m. to 11:25 a.m.

During the course of the tour of the facility, the LPAs observed keys accessible (hanging from the hinge of the door frame) of the staff’s bedroom #4. Residents’ medication are located inside an unlocked cabinet inside bedroom #4, making the medication potentially accessible to residents in care. Additionally, LPAs observed medication in an unlocked cabinet in the unlocked bedroom #9. The LPAs interviewed the administrator about the medication observed in bedroom #9, and the administrator stated that the medication belonged to a resident that was no longer residing at the facility, and medication was not destroyed.

While conducting an assessment of the foods in the pantry, the LPAs observed that a box of approximately 15 containers of Ensure Plus supplements had expired, with an expiration date of 11/ 01/2022 and 12/01/2022.

Record review revealed that the Physician’s Report for Resident #1 was incompletely filled out.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):



Citations were issued. Exit interview conducted, today's report, and appeal rights were reviewed and issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2023
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


Document Has Been Signed on 01/11/2023 03:05 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: 01/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/11/2023
Section Cited

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87555 (b)(8)-The following food service requirements shall apply: All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
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POC-Corrected today as Administrator agreed to throw away the expired food.
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Based on observation of foods found in the pantry, the nutritional drinks had an expiration of 11/ 01/2022 and 12/01/2022, which poses an immediate health and safety danger to persons in care.

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Type A
01/11/2023
Section Cited

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87465(h)(2) The following requirements shall apply to medications which are centrally stored: 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:
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POC: Administrator agreed to secure all medications.
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Based on observation, medications were found in unlocked cabinets and bedrooms and accessible to residents in care, which poses an immediate health and safety danger to persons 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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 01/11/2023 03:05 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: 01/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/11/2023
Section Cited

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87565(i) Prescription medications which are not taken with the resident upon termination of services…shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. This requirement is not met as evidenced by:
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POC: Administrator agreed to destroy the medications....
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Based on observation, medications for a terminated resident were found in the facility, which poses a potential health and safety danger to persons in care.
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Type B
01/11/2023
Section Cited

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87458 (b)(1)-...A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious diseases... This requirement is not met as evidenced by:
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POC: The adminitartor has agreed to have a current physicians report completly filled out in residents file by 1/25/2023. Administrator will fax physician's report to LPA by 1/25/2023.
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Based on record review, the physician report on file for R1 was not completely filled out, which poses a potential health and safety danger to persons 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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3