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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610054
Report Date: 10/19/2023
Date Signed: 10/19/2023 02:45:11 PM


Document Has Been Signed on 10/19/2023 02:45 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:LEO'S ASSISTED LIVING IIFACILITY NUMBER:
197610054
ADMINISTRATOR:DANIELIAN, KHATCHIKFACILITY TYPE:
740
ADDRESS:7567 BOVEY AVENUETELEPHONE:
(310) 292-2992
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:6CENSUS: 4DATE:
10/19/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Khachik Daniellan- AdministratorTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analysts (LPA) Mariana Agban conducted a follow up unannounced visit to this facility in conjunction with a complaint control #31-AS-20231009085600. LPA met with the Administrator and explained the reason for the visit.

After further investigation LPA reviewed and obtained staff records. Records revealed that staff#2 (S2) doesn't have fingerprint and background clearance. Staff#2 (S2) started employment at this facility in June of 2022 and Staff#3 (S3) does have fingerprint and background clearance, but is not associated to this facility. According to S3 they started employment at this facility about two years ago. There were no transfer request forms in the personnel file. The Licensee/Administrator did not request a transfer with the department. This was previously cited on 07-27-2023. Deficiencies and civil penalty issued. Appeal rights given. Exit interview conducted.

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023
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 2


Document Has Been Signed on 10/19/2023 02:45 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
N LA & CEN COA AC/SC, 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: 10/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/20/2023
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)...
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Admnistrator agreed to transfer Staff 3(S3) and assosiate them to the facility.
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This requirement is not met as evidence by:Based on interviews and review of the personnel file one staff(S3) is not associated to the facility.
This poses a potential risk to residents in care.
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Type A
10/20/2023
Section Cited
CCR87355(e)(1)

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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, residing or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department
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Administrator will remove S2 immedatley and will not allow them to return until they obtain background clearance and assosition to the facility. Administrator will sumbit all documents to LPA when complete.
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This requirement is not met as evidence by:Based on interviews and review of the personnel file one staff(S2) is not background cleared to the facility.
This poses a potential risk to residents 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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2