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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610054
Report Date: 10/18/2023
Date Signed: 10/23/2023 04:49:45 PM


Document Has Been Signed on 10/23/2023 04:49 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:
10/18/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Khachik Daniellan- AdministratorTIME COMPLETED:
05:00 PM
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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 it was observed that staff #2 (S2) and staff #3 (S3) were working in the facility without being associated with this facility. Record review revealed S2 and S3 do have fingerprint and background clearance, but is not associated to this facility. Employee records revealed S2 started employment at this facility in June of 2022. In addition, Staff #3 (S3) started employment at this facility about two years. Interviews with residents and staff corroborate S2 and S3 have worked in the facility and provided assistance to residents. Team requested and reviewed personnel files. 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 07-23-2023. A civil penalty will be issued. Due to time constrains LPA was unable to complete citations. The Administrator was informed that additional visit will follow to render the citations.

Copy of this report provided, appeal form given. Exit interview conducted.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2023
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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