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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610111
Report Date: 05/05/2023
Date Signed: 05/05/2023 03:07:57 PM


Document Has Been Signed on 05/05/2023 03:07 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:ANDRANIK KAPIKYANFACILITY TYPE:
740
ADDRESS:9526 SALOMA AVETELEPHONE:
(818) 660-7742
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 6DATE:
05/05/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Adranik Kapikyan, Liana GafikyanTIME COMPLETED:
03:00 PM
NARRATIVE
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In conjunction with a complaint investigation (see control # 31-AS-20230427151459), Licensing Program Analysts (LPAs) Gary Tan and Michael Cava conducted a Case Management (CM) visit to insure the health and safety of the residents in care. The CM visit consisted of a physical plant inspection and record review.
Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiencies were observed and cited (refer to LIC 809-D).
  • The laundry area was left unattended and accessible for residents to enter. LPAs observed laundry detergent and toxins out and accessible to residents.

Administrator was advised, exit interview made, appeal rights and a copy of this report provided.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2023
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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Document Has Been Signed on 05/05/2023 03:07 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: 05/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/05/2023
Section Cited

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Storage Space: Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement has not been met as evidenced by: During a physical plant inspection, LPAs observed laundry detergent
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Prior to the end of the visit, staff locked the laundry area making it inaccessible for residents to enter.
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and toxins, in the laundry area, unattended and accessible to residents in care, which can pose an immediate health and safety risk to the residents 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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2023
LIC809 (FAS) - (06/04)
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