197610054-8-13-2024-31-AS-HRAI-D84SPS-20240813140336

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610054
Report Date: 08/13/2024
Date Signed: 08/13/2024 02:04:28 PM

Document Has Been Signed on 08/13/2024 02:04 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: 4	DATE:	08/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Khatchik Danielian, Administrator		TIME COMPLETED:	02:35 PM

NARRATIVE

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At 9:50 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 11:15 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. Review of medication did not reveal any discrepancy during today's visit.

Bedrooms: LPA observed total of three (3) bedrooms designated for residents use. All bedrooms contained a nightstand, storage, and bed with adequate bedding. All furnishings were clean and in good condition. Facility has an awake staff at the facility. LPA observed half bed rails for resident # (3) in bedroom # (1), without doctor's order. Administrator informed LPA that half bed rails are requested by the family.

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: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

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: 08/13/2024

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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 11:32 AM, hot water temperature measured at 113.4°F.

Common Areas: The facility maintains a comfortable temperature at 78°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 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 06/13/2024.

Smoke detectors/carbon monoxide. The facility has a dual-function smoke and carbon monoxide detectors and at 11:36 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 12:00 PM to 1:15 PM, LPA reviewed records of four (4) residents and two (2) staff. There was no current medical assessment for resident # 1 and resident # 3. Resident last medical assessment was done on 03/22/2022. Resident # 3 did not have any medical assessment and TB test results on file. Residents and staff records appeared to be complete and updated.

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

Deficiencies 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: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/13/2024 02:04 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: 08/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(5)(A)

87608(a)(5)(A). (a) ... Postural supports may be used under the following conditions.(5)Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation during physical plant tour at 11:25 AM, one (1) out of four (4) residient was observed to have a bed rail in bed and there is no physician's order on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/14/2024
	Plan of Correction
1 2 3 4	Administrator agreed to remove half size bed rails. POC cleared during the visit. Administrator agreed to review the section and e-mail LPA verifying it.

Type B

Section Cited

CCR

87458(a)

87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in (2) out of (4) residents did not have a physician's report on file which poses a potential health and safety risk to persons in care.which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/20/2024
	Plan of Correction
1 2 3 4	The Administrator shall submit a current physician's report for Resident # 1 and Residient # 3 to LPA by the POC due date.

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: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 08/13/2024 02:04 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: 08/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(b)(1)

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in (1) out of (4) physical assessment/TB test which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/20/2024
	Plan of Correction
1 2 3 4	Physical assessment needs to done with TB test.

Type B

Section Cited

CCR

87211(a)(1)A,B&D

(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:
	Deficient Practice Statement
1 2 3 4	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 R4's hospitalization on or before 12/23/2024, which poses a potential health and safety risk to persons in care.
	POC Due Date: 08/20/2024
	Plan of Correction
1 2 3 4	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. Licensee provided incident report during the visit POC cleared during the visit.

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: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

LIC809 (FAS) - (06/04)

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