197610054-3-15-2024-31-AS-HRAI-D3DRQC-20240315131319

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610054
Report Date: 03/15/2024
Date Signed: 03/15/2024 01:14:31 PM

Document Has Been Signed on 03/15/2024 01:14 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	LEO'S ASSISTED LIVING II		FACILITY NUMBER:	197610054
ADMINISTRATOR:	DANIELIAN, KHATCHIK		FACILITY TYPE:	740
ADDRESS:	7567 BOVEY AVENUE		TELEPHONE:	(310) 292-2992
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY:	6	CENSUS: 3	DATE:	03/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Khatchik Danielian, Administrator		TIME COMPLETED:	01:40 PM

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At 9:00 AM Licensing Program Analyst (LPA), Huma Rahimi, conducted an unannounced annual inspection at the facility mentioned above. LPA met with staff, Mariam Arzumanyan and later Administrator, Khatchik Danielian, arrived and LPA explained the reason for the visit. Physical tour was conducted with the Administrator and LPA observed the following:

The facility is a single storey building and has three (3) bedrooms for residents use, one (1) office, and two (2) bathrooms. Fire cleared for six (6) non-ambulatory residents, one (1) of which maybe bedridden on Room #1. Hospice waiver for six (6) residents.

Kitchen: At approximately, 9:30 AM LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. Knives and sharps are observed to be locked in the kitchen drawer and inaccessible to residents. Toxins and cleaning solutions were locked under the sink.

Medications: LPA observed that the medication are kept in the filing cabinet inside the office and was observed to be locked and inaccessible to residents in care, however, review of R1's random medication revealed that the facility was supposed to start Lisinopril (Blood Pressure Medication) a new bottle on 03/03/2024. During today's visit LPA counted R1's medication and it was discovered that there was a discrepancy and six (6) extra pills were in the bottle. LPA asked the Administrator and the staff for explaining and both staff could not provide any answers. LPA also observed Centrally Stored Medication (LIC 622) records and did not observe staff filling the box when the medication start date. A deficiency will be cited. There was a complete first aid kit located on top of the medication cabinet in the office.

Bedrooms: LPA observed total of three (3) bedrooms designated for residents use. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Facility has an awake staff.

Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LEO'S ASSISTED LIVING II	FACILITY NUMBER: 197610054
	VISIT DATE: 03/15/2024

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Bathrooms: LPA observed two (2) bathrooms of which one is designated for staff and one for residents. Both appeared to be clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bar and resident’s bathroom had non-skid mat. LPA observed appropriate hand washing signs posted in each bathroom. At 9:47 AM, hot water temperature measured at 111.4°F.

Common Areas: The facility maintains a comfortable temperature at 68°F. The living room and dining area appeared clean and were properly furnished. The living room has a television, comfortable furniture. No obstructions and or tripping hazards throughout the facility. The fireplace was covered with a locked screen. The laundry room is located in the bedroom hallway. Laundry detergent, cleaning solutions and other toxins are observed to be locked inside the laundry room. A new and charged fire extinguisher hung near the kitchen purchased on 03/15/2024.

Smoke detectors/carbon monoxide. The facility has a dual-function smoke and carbon monoxide detectors and at 9:55 AM, they were tested and observed to be operational.

Garage: There is no garage at the facility only drive ways.

The Backyard/Outside: had a covered shaded area for residents with outdoor furniture. There is no body of water at the facility. The facility has only one emergency exit. The emergency exit was unlocked with an inward facing latch. Emergency exit paths were free from debris.

Between 10:00 AM to 11:45 AM, LPA reviewed records of three (3) residents and three (3) staff. Residents and staff records appeared to be complete and updated.

Administrative: LPA collected Certificate of Liability Insurance, and LIC500.

A deficiency cited on LIC 809D.

Exit interview conducted. Appeal rights explained and copy of this report signed and delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/15/2024 01:14 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.RO, 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: 03/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(c)(2)

87465- Incidental Medical and Dental Care: c) If the resident's physician has stated in writing... 2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on (observation) (interview) (record review)], the licensee did not comply with the section cited above in not assuring that R1's prescibed medications were given as prescribed, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/18/2024
	Plan of Correction
1 2 3 4	Administrator agreed to schedule vendorized training for all staff by 03/18/2024 and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion. Administrator also agreed to notify doctor and submit LIC 624 to CCL regarding the incident.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024

LIC809 (FAS) - (06/04)

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