197610054-11-9-2022-31-AS-NRED-CKZUD7-20221109142905

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610054
Report Date: 11/09/2022
Date Signed: 11/09/2022 02:29:14 PM

Document Has Been Signed on 11/09/2022 02:29 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 II		FACILITY NUMBER:	197610054
ADMINISTRATOR:	ARAKELIAN, ARMINE		FACILITY TYPE:	740
ADDRESS:	7567 BOVEY AVENUE		TELEPHONE:	(310) 292-2992
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY:	6	CENSUS: 3	DATE:	11/09/2022
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Egda Pastora Castro		TIME COMPLETED:	02:45 PM

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At approximately 9:20 a.m. on 11/09/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced Plan of Correction visit. LPA met with staff and disclosed the reason for the visit.

On 09/28/2022 LPA investigated complaint #31-AS-20220923175322 and substantiated the allegation of resident records not maintained at the facility. A Proof of Correction due date was set for 10/28/2022. LPA called Administrator Armine Arkelian and Licensee Anna Gharibyan to remind them of the POC due date. LPA called Administrator Armine Arkelian on 11/08/2022 to remind that the Proof of Correction was not received in time.

On 11/09/2022 at 9:35 a.m. LPA reviewed resident records at the facility as part of complaint investigation #31-AS-20221108101558. LPA observed the following deficiencies:

Resident #1 (R1) had an Admission Agreement with missing signatures and no date, no LIC 602A Physician’s Report, an incomplete LIC 603 with no date, an incomplete LIC 621 with missing signatures and no date, and an incomplete LIC 625 Needs and Service Plan with missing signatures and no date.

Resident #2 (R2) had an Admission Agreement with no signature and no date, an incomplete LIC 603, and an incomplete LIC 625 Needs and Service Plan.

Resident #3 (R3) had no LIC 602A Physician’s Report, an incomplete LIC 603 with missing signatures and no date, and an incomplete LIC 625 Needs and Service Plan.

Due to the failure to correct the deficiency cited on 09/29/2022, a civil penalty of $100 per day is hereby assessed for the period of 10/29/2022 – 11/09/2022 in the amount of $1,200 (12 days x $100/day). Daily civil penalties will continue to accrue until the deficiency is corrected. The civil penalty is issued on the attached LIC 421FC page.

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

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022

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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