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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610111
Report Date: 01/10/2024
Date Signed: 01/18/2024 12:28:08 PM


Document Has Been Signed on 01/18/2024 12:28 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 01/18/2024 12:17 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

NARRATIVE
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This is a AMENDED report as after further review of the substantiated and deficiency findings on 1/10/24 of the above-mentioned allegation. Civil penalty has been removed and corrected. NO FINE on facility.

On 1.10.2024, Licensing Program Analyst (LPA) Leslie Ngo-Castaneda arrived at the facility. LPA was greeted by staff Isiah Phiri (S1) and later met with Administrator Aranik Kapikyan. The purpose of this Case Management – Deficiencies report is to address deficiencies found during the complaint investigation, control number 31-AS-20231227160159.

LPA conducted a physical plant tour and at 9:2 AM, LPA observed that three (3) out of six (6) clients needed assistance for changing, food preparation, and cleaning. LPA Ngo-Castaneda observed a resident was left alone on 1.10.2024 without staff present to meet R2, R4 and R5's needs. A copy of the LIC 500 was provided to LPA Ngo-Castaneda.



Administrator did not provide incontinent management program for R2, this was already address during the initial visit. According to R1, R2’s soiled diaper is expose in the hallway for staff to clean-up. R2 used to throw soiled diaper across the bedroom with R1. LPA also observed during the visit that a urine odor is present in the residents bedroom hallway.

Based on observation, deficiencies issued per CA Code of Regulation, Title 22. See 809-D.

Exit interviewed discussed, appeal rights were given to the caregiver and a copy of the signed report was given to administrator.


SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-CastanedaTELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2024
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 01/18/2024 12:29 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 01/18/2024 12:21 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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: 01/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/10/2024
Section Cited
CCR
87411

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Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
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Administrator needs to have another hire and have at least two (2) staff in the facility during the visit. A new LIC 500 is needed, this would be sent via email from administrator.
NO civil penalty has been issued.
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Type B
01/10/2024
Section Cited
CCR87625(b)(3)

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Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.
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Administator needs to updated on bowel and bladder plan for R2. An update on resident appraisal as well. Administrator will email to LPA.
NO civil penalty has been issued.
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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) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-CastanedaTELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2