197610094-3-7-2024-31-AS-MAGN-D3662G-20240307192530

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610094
Report Date: 03/07/2024
Date Signed: 03/07/2024 07:27:16 PM

Document Has Been Signed on 03/07/2024 07:27 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	WELLNESS ASSISTED LIVING		FACILITY NUMBER:	197610094
ADMINISTRATOR:	MELIKSETYAN, LUSINE		FACILITY TYPE:	740
ADDRESS:	9115 N WYSTONE AVE		TELEPHONE:	(747) 218-9141
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY:	6	CENSUS: 5	DATE:	03/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Ruzanna Manukyan- Administrator Designee		TIME COMPLETED:	04:45 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	Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with staff and explained the reason for the visit. Staff informed LPA that they were unable to understand English and called Administrator LUSINE MELIKSETYAN who could not attend today's visit. Administrator Designee Ruzanna Manukyana arrived shortly after. At 10:10 AM LPA took a tour of the physical plant. Required postings were observed in the entry area. LPA observed dining room ceiling had water stains and cracks in the ceiling. Staff had an empty packet in the middle of the floor to gather the water dripping off the roof. LPA asked the Administrator Designee regarding the roof leaking and when it happened. Administrator Designee stated that the leak happened last week due to the rain. Administrator Designee stated that the property owner will fix the roof when the rain stops. LPA advised the Administrator Designee that this poses a potential health and safety to residents in care. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the office cabinets. The fire extinguisher is located in the kitchen with a purchase date of 7/11/23. Smoke alarms and carbon monoxide were tested and are functional. Bedrooms: The facility has four (4) bedrooms of which one is a shared room. All four (4) bedrooms were toured and appear to be clean and properly furnished. Bathrooms: There are two (2) bathrooms designated for residents' use. All bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 113.8 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathroom during the inspection. Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The laundry room: was locked and inaccessible to residents. Resident Files: LPA conducted a file review of resident records to ensure compliance with licensing forms. Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WELLNESS ASSISTED LIVING	FACILITY NUMBER: 197610094
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

87465(a)(4)

The licensee shall assist residents with self-administered medications as needed
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above. which poses an immediate health, safety or personal rights risk to persons in care. R1's centrally stored medication and destruction record is missing all information regarding the medication name and start date. R2's centrally stored medication and destruction record is missing the start date. R3 Buprenorphine Medication was missing doses for March 11,12,13, and 14. The medication is instructed to take one tablet daily. LPA also observed that Quetiapine is missing 56 tablets.
	POC Due Date: 03/08/2024
	Plan of Correction
1 2 3 4	Administrator Designee agreed to provide complete Centrally Stored Medication Records for R1, R2, and R3 and in writing an explanation of the reason for missing doses of R3 of Buprenorphine and Quetiapine medication. Administrator designee will email LPA proof of corrections by the POC date.

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: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WELLNESS ASSISTED LIVING	FACILITY NUMBER: 197610094
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

This requirement is not met as evidenced by:87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times.
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above. LPA observed dining room ceiling had water stains and cracks in ceiling. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/14/2024
	Plan of Correction
1 2 3 4	Administrator will sent pictures of fixed roof by the POC date.

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: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/07/2024 07:27 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WELLNESS ASSISTED LIVING	FACILITY NUMBER: 197610094
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

87412(g)

This requirement is not met as evidenced by: 87412 Personnel Records (g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.
	Deficient Practice Statement
1 2 3 4	Based on observation , the licensee did not comply with the section cited above. Administrator designee had no physical file at the facility. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/14/2024
	Plan of Correction
1 2 3 4	Administrator will provide scan copy of Administrator Designee folder by the POC date.

Type B

Section Cited

CCR

87411

This requirement is not met as evidenced by: 87411 Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review the licensee did not comply with the section cited above in. LPA observed missing training for S1 and S2. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/14/2024
	Plan of Correction
1 2 3 4	The administrator will provide proof that S1 and S2 took February training on infection control and on Dementia behavioral changes. Administrator will conduct appropriate medication training will be provided for all medication staff members. Administrator will submit the training documentation to LPA.

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: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WELLNESS ASSISTED LIVING	FACILITY NUMBER: 197610094
	VISIT DATE: 03/07/2024

NARRATIVE

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LPA observed that S1 and S2 are not on the training list for February Administrator Designee stated that they have taken training's but their names were not on the list. LPA also observed that S1 and S2 had not signed any of the training's that the Administrator Designee stated they took. In addition, LPA oberved there's no physical file of Administrator Designee. Medications: Medication and Medication Records were reviewed for proper documentation. LPA observed that R1's centrally stored medication and destruction record is missing all information regarding the medication name and start date. R2's centrally stored medication and destruction record is missing the start date. R3 Buprenorphine Medication was missing doses for March 11,12,13, and 14. The Buprenorphine medication is instructed to take one tablet daily. LPA was informed that the staff had a doctor's order to give this medication twice a day instead of once. LPA requested to see medication instructions change but staff couldn't provide them. LPA also observed that Quetiapine is missing 56 tablets. Exit Interview Conducted, citations issued, copy of the report delivered and appeal rights given.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

LIC809 (FAS) - (06/04)

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