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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610031
Report Date: 12/06/2022
Date Signed: 12/06/2022 08:02:47 PM


Document Has Been Signed on 12/06/2022 08:02 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: DATE:
12/06/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Nirvana GhaemiTIME COMPLETED:
03:30 PM
NARRATIVE
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On 12/06/2022, Licensing program Analyst (LPA) Sandra Urena, conducted an unannounced Case Management-Deficiencies inspection visit at 3:10 p.m. due to deficiencies observed during the investigation of complaint control # 29-AS-20221205152932. The LPA met with Administrator Nirvana Ghaemi, and explained the reason for the visit.

At 10:17 a.m., LPA Urena, and the Administrator conducted a tour of the facility. During the tour, it was observed that two (2) residents occupied bedroom#1, two (2) residents occupied bedroom #2, two (2) residents occupied bedroom #6, and one (1) resident occupied bedroom #5. Total number of residents was observed to be seven(7). The facility is licensed for a capacity of six(6) residents. The Administrator stated that the resident in bedroom #5 was fingerprinted, and was associated to the facility as an employee. The resident in bedroom #5 is not related to the Administrator or the licensee. The resident was not observed acting as an employee of the facility. Record review revealed that the resident in bedroom #5 was admitted as a resident to the facility on 9/16/2022, based on the Admission Agreement found on file, and the resident's POA is paying a board and care fee to the licensee. The resident passed away during the case management visit, consequently the licensee will not be required to inform the Fire Department of the over capacity.

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: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022
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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Document Has Been Signed on 12/06/2022 08:02 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: 12/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/09/2022
Section Cited

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(a) A licensee shall not operate a facility beyond the condition and limitations specified on the license, incuding specifications of the maximum number of persons served who may recieve services at any one time. This requirement is not met as evidenced by:
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Based on observation and record review, the facility was serving seven residents, which is over the allowed capacity. This 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: 12/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2