197610122-3-5-2024-31-AS-PKHN-D33U5C-20240305141632

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610122
Report Date: 03/05/2024
Date Signed: 03/05/2024 02:17:48 PM

Document Has Been Signed on 03/05/2024 02:17 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	EATON CANYON VILLAS II INC.		FACILITY NUMBER:	197610122
ADMINISTRATOR:	GARIBYAN, ARMOND		FACILITY TYPE:	740
ADDRESS:	2520 GANESHA AVE		TELEPHONE:	(818) 429-0070
CITY:	ALTADENA	STATE: CA	ZIP CODE:	91001
CAPACITY:	6	CENSUS: 3	DATE:	03/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:			TIME COMPLETED:	02:45 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	At 10:00am Licensing Program Analysts (LPAs) Perchui Milena Khurshudyan and Rahimi Huma conducted an unannounced annual inspection at the facility mentioned above. LPAs met with facility staff Olga Socop and informed the reason for the visit, Olga granted access to the facility. At approximately, 10:10am physical tour was conducted LPAs observed the following: Kitchen: At approximately, 10:10am LPAs toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. Canned non expired food was stored in kitchen and in the garage pantries. All knives and sharps are observed to be locked in a locked in the kitchen drawers and inaccessible to residents. The facility has a working gas stove, microwave, refrigerator and freezer. There is a fully charged fire extinguisher in the kitchen and last purchased on 11/09/2023. Bedrooms: At approximately 10:30am LPAs checked the bedrooms. There are three (3) bedrooms designated for 6 residents use. All rooms were observed to have sufficient lighting, and are properly furnished, clean and have appropriate bedding and linens. There is enough linens to be change every week or when necessary in a cabinet in the hallway. Bathrooms: At 10:35am LPAs observed one (1) bathroom, the bathroom is clean and in good repair. Properly supplied with toilet papers, soap and paper towels. Bathroom is located beside bedroom #1 and #2 has a hot water temperature measured at 115°F. LPAs observed appropriate grab bar and had non-skid mat. LPAs observed appropriate hand washing signs posted in each bathroom. All trash cans in bathrooms had fitted lids to protect from cross contamination. Continue on LIC 809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui Khurshudyan	TELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: EATON CANYON VILLAS II INC.	FACILITY NUMBER: 197610122
	VISIT DATE: 03/05/2024

NARRATIVE

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Medications: At approximately, 10:25am LPAs observed medications are centrally stored and locked in the
cabinet, inside locked staff room by the living room area and inaccessible to residents in care. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the clients’ doctor. Proper medication dispensing instruction are followed and checked for contamination. First-aid has all proper items and is current.

The laundry room is located outside in the separate area with proper lock. LPAs observed all detergents locked and inaccessible to residents in care.

Common Areas: The facility maintains a comfortable temperature at 73°F. The living room and dining area appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility found. Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, and observed to be operational. They are cleared for six (6) no ambulatory clients. No issue with fire clearance.

Outside areas: At approximately, 10:50am LPAs toured the outside area of the facility. LPAs observed appropriate outdoor furniture, with a covered shaded area for clients. Exit area are free of obstructions and hazards. LPAs checked inside of the locked shed it was used for facility maintenance purposes. LPAs discussed the importance of maintaining the care and supervision to meet the needs of residents. The facility does not have a swimming pool or body of water. There is a garage used for additional PPE supplies.

Between 11:30am to 1:00pm, LPAs reviewed records of three (3) residents, and zero (0) staff records. LPAs couldn’t verify staff records and as well complete residents’ records.

Administrative: LPAs collected Administrator Certificate, infection control, LIC 500, LIC 9020, regional report.

Citations issued during this visit and appeal rights were provided. Exit interview conducted. Copy of report printed and handed to Licensee.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui Khurshudyan	TELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/05/2024 02:17 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: EATON CANYON VILLAS II INC.	FACILITY NUMBER: 197610122
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(a)

87506 (a) Resident Records. The Licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative locaton readily available to facility staff and to licensing staff. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not maintaining complete facility files for residents which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/12/2024
	Plan of Correction
1 2 3 4	License/Administrator will complete files for all residents. Once completed licensee/administrator will submit a complete files for the residents and TB test results for all the residents.

Type B

Section Cited

CCR

87412(a)

Personnel Records. Personnel records shall be maintained on the licensee, administrator and each employee, and shall contain specified information. LPA was unable to review all staff files on duty during this visit, due to licensee not have any personnel records for the staff. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Personnel Records. Personnel records shall contain verification of required staff training and orientation, as specified. Licensee did not have documentation of training or orientation for the (3) staff observed by LPA on this visit. This poses potential health and safety risk to residents in care.
	POC Due Date: 03/12/2024
	Plan of Correction
1 2 3 4	Licensee has agreed to prepare personnel files for all staff present at the facility. It includes, TB clearance, Good Health Statement, LIC501(employment application), verification of age, documentation of orientation training, verification of first aid, LIC508 criminal record statement, criminal record clearance

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 Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui Khurshudyan	TELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024

LIC809 (FAS) - (06/04)

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