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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610111
Report Date: 02/08/2023
Date Signed: 02/08/2023 12:23:33 PM


Document Has Been Signed on 02/08/2023 12:23 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:CALIFORNIA STATE HEALTH GROUP LLCFACILITY NUMBER:
197610111
ADMINISTRATOR:SIMITYAN, ARMENUIFACILITY TYPE:
740
ADDRESS:9526 SALOMA AVETELEPHONE:
(818) 660-7742
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 5DATE:
02/08/2023
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Andranik KapikyanTIME COMPLETED:
11:20 AM
NARRATIVE
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On 2/8/2023, Licensing Program Analyst (LPA) Melissa Ruiz arrived at the facility. LPA was greeted by staff (S1) and later met with Administrator Armenui. LPA The purpose of this Case Management – Deficiencies report is to address deficiencies found during the complaint investigation, control number 31-AS-20230131130307.

LPA conducted a physical plant tour and at 10:15 a.m., LPA observed medication accessible to residents in care in the dining room area. Shortly after, Administrator observed the medication and stored the medication away. Based on observation, deficiencies issued per CA Code of Regulation, Title 22. See 809-D.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2023
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 2


Document Has Been Signed on 02/08/2023 12:23 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: CALIFORNIA STATE HEALTH GROUP LLC
FACILITY NUMBER: 197610111

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/10/2023
Section Cited

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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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The Administrator has stated in-house training will be conducted among all staff and a signed written statement will be submitted by the POC due date.
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Based on observation, the Administrator did not comply with the section cited above in which LPA observed medicati near the kitchen, accessible to residents in care. This poses an immediate health and safety risk or personal rights risk to resdients in care.
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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 GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2