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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610143
Report Date: 05/09/2022
Date Signed: 05/10/2022 06:31:27 PM


Document Has Been Signed on 05/10/2022 06:31 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 05/10/2022 01:46 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

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Licensing Program Analyst (LPA), Yelena Avetisyan, conducted an unannounced annual inspection at the facility mentioned above. LPA was greeted by staff Cynthia Sherriel. Administrators Jack Berghoudian and Naira Paroyan arrived approximately 4:40 pm. Upon entrance to the home while speaking with staff LPA observed an unknown individual sitting on the couch. The individual walked towards the kitchen and could not be located afterwards. Per staff the individual was her friend who was just visit her. LPA asked how long staff is working at the facility. Per staff this was her first day working at the facility. However while speaking with LPA the staff able to provide information regarding 2 prior residents and why they are no longer at the facility. The residents also appeared very familiar with the staff. The staff member does not have criminal record clearance.
Infection control: LPA reviewed the facility mitigation plan to ensure compliance with the infection control recommendations. Upon arrival, LPA was not screened and not asked to sign-in the visitors’ log. In addition, LPA was asked all infection control questions. Proper signage was not observed at the facility. Administrators stated they have sufficient PPE supplies for clients and staff however were not able to show the LPA.

Kitchen: At 10:15am LPA toured the kitchen area and did not observed 2 day perishable and 7 day non-perishable/emergency food/water at the facility. The three fire extinguisher (s) were purchased on 03/12/2021.

Medications: LPA observed medications are centrally stored and locked in a cabinet along with all knives and sharps and inaccessible to clients in care. LPA also observed medications placed inside the refrigerator accessible to residents.



Common Areas: The facility maintains a comfortable temperature at 73°F. The living room and dining area were properly furnished. The door screen and shades on the backyard door was broken.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2022
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


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: VELVET CARE
FACILITY NUMBER: 197610143
VISIT DATE: 05/09/2022
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Bedrooms: There are four (4) bedrooms and (2) bathrooms designated for resident use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. While touring the Bedrooms LPA observed the following.
  • Rm # 1 Light Switch broken.
  • Rm # 2 1 bed was blocking the exit door and second bed was blocking the closet.
  • Room # 2 had a strong urine odor
  • Room # 3 Vacant
  • Rm # 4 Strong urine Odor. .

Bathrooms: LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels.. LPA did not observe appropriate hand washing signs posted in each bathroom.



Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 7:00 pm they were tested and observed to be operational.

Outside areas: At 4:27pm LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, without a covered shaded area for clients. LPA also observed a nail placed on the exit gate to prevent the lock from opening. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients without locking them in the facility. . There are no bodies of water.

From 4:45 pm LPA conducted review of facility file for 4 current residents and prior residents who have passed away. While reviewing residents records LPA observed all files were outdated, missing documents and not properly completed. Information obtained from file reviews revealed that licensee was retaining 5 residents who were receiving hospice services, however licensee has a hospice waiver for 4. While reviewing resident files LPA observed that Resident 2 (R2) was admitted to the facility from Brilliant Corners. Administrators confirmed that they receive P&I funds for R2 but do not have a Surety Bond and have not been Documenting the P&I funds as required.

Due to time constraints, LPA was not able to complete the inspection and issue citations for the observed deficiencies. LPA will return at a later date to issue the citations/civil penalties and complete inspection. Exit interview conducted and copy of report emailed.

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2