197610054-12-8-2022-31-AS-NRED-CLX2BG-20221208161506

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610054
Report Date: 12/08/2022
Date Signed: 12/08/2022 04:15:17 PM

Document Has Been Signed on 12/08/2022 04:15 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: 5	DATE:	12/08/2022
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Khatchik Danielian		TIME COMPLETED:	04:30 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

At 2:45 p.m. on 12/08/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with the Administrator 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.

At 12:15 p.m. on 12/08/2022 LPA reviewed resident records at the facility as part of complaint investigation #31-AS-20221202164248. LPA observed the following deficiency:

The facility did not maintain records for Resident #1 (R1), Resident #2 (R2), nor Resident #3 (R3).

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 – 12/08/2022 in the amount of $2,900 (29 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.

At 4:00 p.m. on 10/27/2022 LPA conducted a case management visit. LPA requested to view staff records. No staff records were available for audit. A deficiency was issued with a Plan of Correction date of 11/25/2022.

At 12:15 p.m. on 12/08/2022 LPA requested staff records. The Administrator noted the facility did not maintain staff records for previous or current staff. Staff records were not available for audit.

Due to the failure to correct the deficiency cited on 10/27/2022, a civil penalty of $100 per day is hereby assessed for the period of 11/26/2022 – 12/08/2022 in the amount of $1,300 (13 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.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022

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 3

Document Has Been Signed on 12/08/2022 04:15 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
CCLD Regional Office, 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: 12/08/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/08/2022 Section Cited	1 2 3 4 5 6 7	87355 Criminal Record Clearance (e) All individuals subject to a criminal record review... shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by:
	8 9 10 11 12 13 14	Based on file review, the licensee did not comply with the section cited above in 2 out of 3 employees which poses an immediate Health, Safety, or Personal Rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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
	VISIT DATE: 12/08/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Additionally, Staff #1 (S1) and Staff #2 (S2) did not maintain criminal background clearances and were not associated to the facility. The Administrator noted S1 began employment on 11/21/2022 and S2 began on 12/07/2022.

An additional civil penalty is assessed due to a repeated violation of the same regulation within 12 months.

The deficiency are cited on the attached LIC 809-D page. Civil penalties are issued on the attached LIC 421BG page and LIC 421FC page

Exit interview conducted. Copy of report, appeal rights, and citation(s) issued.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3