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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610054
Report Date: 10/18/2023
Date Signed: 10/19/2023 09:24:46 AM


Document Has Been Signed on 10/19/2023 09:24 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
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:
10/18/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Khachik Daniellan- AdministratorTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Mariana Agban and Huma Rahimi conducted unannounced visit to this facility in conjunction with a complaint control #31-AS-20231009085600. LPAs met with the Administrator and explained the reason for the visit.

During the visit, LPAs observed two (2) incidents for 2 residents that were not submitted to the Community Care Licensing Department (CCLD) in a timely manner. Moreover, Administrator informed LPAs that R1 was hospitalized on 10/03/2023. LPAs reviewed all incident reports on a system and did not observe an Incident Report regarding R1. In addition, the Administrator admitted that no incident was submitted to the Regional Office (RO). Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPAs informed the Administrator that all staff members are mandated reporters and they are all responsible for reporting.

LPAs informed the Administrator to submit the following two (2) incidents that occurred on:
  • 10/03/2023 (one incident)
  • 10/06/2023 (one incident)


In addition, review of R1's record revealed that the facility file is incomplete/missing documents.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC 809D.
Exit interview conducted, appeal rights and copy of report signed and delivered.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2023
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 10/19/2023 09:24 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
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: 10/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2023
Section Cited
CCR
87211(a)(1)A,B,D

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Requirements
(a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)...
This requirement is not met as evidenced by:
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Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. Copies of 2 incidents, shall be submitted to LPA by POC date.
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Based on interviews and record reviews, conducted by LPA, the licensee did not comply with the section cited above by failing to notify CCLD regarding the five (5) incidents that occured on 10/3/23 and 10/6/23 which poses a potential health and safety risk to persons in care.
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Type B
10/25/2023
Section Cited
CCR87506(a)

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87506 Resident Records: (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility...

This requirement is not met as evidenced by:
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Administrator will sumbit a written explanation on how to manage residents files for future addmissions.
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Based on record review, the licensee did not comply with the section cited above. Resident records were incomplete and or missing documents, which poses/posed a potential health, safety or personal rights risk 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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2023
LIC809 (FAS) - (06/04)
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