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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610054
Report Date: 07/27/2023
Date Signed: 07/27/2023 05:03:10 PM


Document Has Been Signed on 07/27/2023 05:03 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:LEO'S ASSISTED LIVING IIFACILITY NUMBER:
197610054
ADMINISTRATOR:ARAKELIAN, ARMINEFACILITY TYPE:
740
ADDRESS:7567 BOVEY AVENUETELEPHONE:
(310) 292-2992
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:6CENSUS: 3DATE:
07/27/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Sona Gevorkyan, designeeTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst(LPA) Antonia Alvizar and Licensing Program Manager (LPM) met with facility Designee Sona Gevoryan for a plan of correction visit.
The purpose of the plan of correction visit is to clear deficiency issued 07-05-2023.
Entrance interview conducted.
At 10:20 am LPA requested a copy of the liability insurance. The facility Designee was unable to locate the document, Mr. Khatchik Danielian(Administrator) was contacted.
LPM spoke with Khatchik Danielian and requested the liability insurance as the department as requested on a previous visit 07-05-2023. Mr. Danielian stated that a request for liability insurance has been made but does not have a current copy.
As a result, the plan of correction is not met. Because the department did not clear the plan of correction within 10-days of it being due a new deficiency will be issued.
In addition, it was discovered that facility designee Sona Gevoryan has not provided documentation to associate herself to the department therefore is not associated to the facility. She stated she just started today and will fax a copy into the department for association. In addition in the course of today, visit it was discovered that staff #2 is not associated to the facility. A citation and civil penalty will be issued.
Other observations: LPM requested that the security straps on the cabinets be replace as there are issues with them sticking to the cabinet door and they can be easily ripped off making chemical, medications, etc. accessible.

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023
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 4


Document Has Been Signed on 07/27/2023 05:03 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: LEO'S ASSISTED LIVING II
FACILITY NUMBER: 197610054

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/28/2023
Section Cited
CCR
87355(e)(2)

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All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... in a licensed facility: (2)Request a transfer of a criminal record clearance as specified in Section 87355(c)... This requirement is not met as evidence by:
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The facility designee has agreed to provide the LPA with copies of documentation to associate to the facility. Today LPM collected documentation for staff 1. Staff #2 documentation is needed. Submit transfer form and clear copy of ID.
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Based on interview and review of licensing report summary facility Designee is not associated to the facility. No documentation to associate staff/designee has not been submitted.
This poses a potential risk to residents in care.
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Type B
07/28/2023
Section Cited
CCR1569.605

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ยง1569.605 Liability insurance; coverage requirements On and after July 1, 2015...


This requirement is not met as evidence by:
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Licensee will review the health and safety code, obtain liability insurance as required by the health and safety code. Copy of the current liability insurance certificate will need to be
submitted as POC.
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Based on records reviewed, and interview with the administrator facility does not have current liability insurance coverage.
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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: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: LEO'S ASSISTED LIVING II
FACILITY NUMBER: 197610054
VISIT DATE: 07/27/2023
NARRATIVE
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This visit was conducted in conjunction with today complaint 31-AS-20230724090132 visit, the following deficiencies where observed to be in violations however were not alleged on the complaint:

Staff are providing wound care and staff are not appropriate skilled wound care professionals.
Administrator has not documented all aspects of wound care in the resident #1 file.

Deficiency and appeal rights issued.
Exit interview conducted.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/27/2023 05:03 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: LEO'S ASSISTED LIVING II
FACILITY NUMBER: 197610054

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/03/2023
Section Cited
CCR
87631(a)(1)

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Except as specified in Section 87611(a), the licensee shall be permitted to accept or retain a resident who has a healing wound under the following circumstances:
(1) When care is performed by or under the supervision of an appropriately skilled professional. This requirement is not met
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Administrator has agreed to have hospice document that staff has been trained on certain wound care issues. Need to obtain complete hospice care plan outling the stage of the wound. The resident reappraisal and needs and service needs to reflect the resident wounds and how staff can assist.
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as evidence by:
Based on interview staff are providing wound care and staff are not appropriate skilled wound care professionals.

This poses a potential risk to residents in care.
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Type B
08/03/2023
Section Cited
CCR87631(a)(3)(B)

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Except as specified in Section 87611(a), the licensee shall be permitted to accept or retain a resident who has a healing wound..(3)... pressure injury must have the condition diagnosed by a physician or an appropriately skilled professional. (B) All aspects of care
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 Administrator has agreed to have hospice document that staff has been trained on certain wound care issues. Need to obtain complete hospice care plan outling the stage of the wound. The resident reappraisal and needs and
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performed by the medical professional and facility staff shall be documented in the resident's file. This requirement is not met as evidence by: Based on interviews and file review the facility is not documenting all aspects of care for R1 This poses a potential risk to residents in care.
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service needs to reflect the resident wounds and how staff can assist.
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: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023
LIC809 (FAS) - (06/04)
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