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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610123
Report Date: 10/25/2021
Date Signed: 10/25/2021 12:25:30 PM

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:CONCORDIA ASSISTED LIVINGFACILITY NUMBER:
197610123
ADMINISTRATOR:YEGEYAN, NAZARFACILITY TYPE:
740
ADDRESS:16704 BLACKHAWK STREETTELEPHONE:
(818) 403-1803
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:6CENSUS: 5DATE:
10/25/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Nazar (Nick) YegryanTIME COMPLETED:
12:40 PM
NARRATIVE
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility in response to an Incident Report received in the CCL office on 10/18/2021. Upon entry, the LPA's temperature was taken and covid 19 questions were asked. The administrator was called and came to the facility at around 10:15 AM.

The LPA explained to the staff that the LPA was at the facility in regard to an elopement of a resident (R1) that was reported to the community care office. Staff indicated that R1 had got up late at night and had opened the sliding door in R1's room and had walked away from the facility. At 10:00 AM, LPA tested all doors and sliding doors to ensure that the alarms were functioning properly. Rooms 1 and 2 were observed to have sliding doors and the alarm did not go off when the LPA tested them. At 10:45 AM, the administrator showed the LPA that the sliding doors need to be completely closed for the alarm to set. Once the administrator opened and closed the door, the alarms did work. The LPA explained that the door alarms need to be functional, regardless of how the door is closed and that their can't be some type of trick to set the alarm.

At the time of the elopement, there were two staff at the facility. Both staff denied hearing the alarm go off and realized R1 was not in the room while conducting hourly checks. The police were immediately informed and so were R1's responsible party and the administrator. R1 was located a short while later and returned to the facility.

No further information gained. Exit interview conducted, deficiencies cited and report issued.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CONCORDIA ASSISTED LIVING
FACILITY NUMBER: 197610123
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2021
Section Cited

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Care of Persons with Dementia. The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met as evidenced by:
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Based on LPA observation, the administrator did not have an auditory device that would work every time resulting in an AWOL of R1, which is an immediate risk to the health and safety of 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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2021
LIC809 (FAS) - (06/04)
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