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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610054
Report Date: 11/08/2022
Date Signed: 11/08/2022 01:41:00 PM

Document Has Been Signed on 11/08/2022 01:41 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., 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:
11/08/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Egda Pastora CastroTIME COMPLETED:
01:50 PM
NARRATIVE
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At 11:15 a.m. on 11/08/2022 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced, initial complaint visit of complaint #31-AS-20221108101558 . LPA met with staff and disclosed the reason for the visit. LPA and staff toured the facility at 11:25 a.m. and observed medication accessible. The medication was also removed form its original container and organized in a separate pill container.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the deficiency was cited (refer to LIC 809-D).

Exit interview conducted. Appeal rights discussed. Copy of report provided.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2022
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 11/08/2022 01:41 PM - It Cannot Be Edited


Created By: Nicholas Reed On 11/08/2022 at 01:22 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 11/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/09/2022
Section Cited
CCR
87465(h)(5)

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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (5) ...medication shall be stored in its originally received container. No medications shall be transferred between containers.
This requirement is not met as evidenced by:
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Licensee will conduct an in-service training on the cited section for all staff handling medication and submit proof by the POC due date.
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Based on observations, the licensee did not comply with the section cited above in 1 out of 3 residents which 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:Cassandra Harris
LICENSING EVALUATOR NAME:Nicholas Reed
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2022


LIC809 (FAS) - (06/04)
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