Community Care Licensing

SUPERVISOR'S NAME: Eva Miller TELEPHONE: (818) 596-4373 LICENSING EVALUATOR NAME: Yelena Avetisyan TELEPHONE: (818) 378-8120 LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2022

FACILITY NAME: VELVET CARE	FACILITY NUMBER: 197610143
	VISIT DATE: 05/10/2022

FACILITY NAME: VELVET CARE	FACILITY NUMBER: 197610143
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/10/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/10/2022 Section Cited	1 2 3 4 5 6 7	87355(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or...
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews and record reviewed the licensee did not comply with the section cited during the 5/9/22 and 5/10/22 visit by not obtaining a criminal record clearance for S1 and S2 prior to working at the facility. which poses an immediate health, safety and personal rights risk to persons in care.	8 9 10 11 12 13 14
Type A 05/10/2022 Section Cited	1 2 3 4 5 6 7	FIRE CLEARANCE. All facilities shall maintain a fire clearance. Prior to accepting persons over 60 years of age none ambulatory and/or bedridden the licensee shall notify the licensing agency and obtain an appropriate fire clearance. This requirement is not met as evidenced by:
	8 9 10 11 12 13 14	Based on interview and record review, the licensee did not comply with the section cited above retaining 1 bedridden residents in Rm #3 which does not have bedridden fire clearance which posed an immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14	This is a zero tolerance violation therefore civil penalty in the amount of $500 has been issued.

SUPERVISOR'S NAME: Eva Miller TELEPHONE: (818) 596-4373 LICENSING EVALUATOR NAME: Yelena Avetisyan TELEPHONE: (818) 378-8120 LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2022

Document Has Been Signed on 05/10/2022 06:34 PM - It Cannot Be Edited

FACILITY NAME: VELVET CARE	FACILITY NUMBER: 197610143
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/10/2022

Type A

Section Cited

CCR

87203

Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and receipt review, the licensee/administrators did not comply with the section cited as the 3 fire extinguishers were purchased on 3/12/2021 and have not been serviced since which poses an immediate health, safety and personal rights risk to persons in care.
	POC Due Date: 05/11/2022
	Plan of Correction
1 2 3 4	Licensee/Administrator will have fire extinguisher serviced or purchase a new one. Licensee/administrator will submit documentation to confirm servicing of the fire extinguisher or submit photo and receipt confirming purchase of a new fire extinguisher. This is a zero tolerance violation therefore a civil penalty in the amount of $500 dollars has been assessed/issued. Civil Penalty in the amount of $100 dollars per day will continue to accrue until POC has been received.

Type A

Section Cited

CCR

87705(I)(2)

The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates. This requirement is not met as evidenced by: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations and file review, the licensee did not comply with the section cited above by not having the appropriate fire clearance to lock placing a nail to prevent the property's gated perimeter fence from opening which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/10/2022
	Plan of Correction
1 2 3 4	Administrator removed nail from the lock during the visit. Administrator will provide a signed statement of understanding and intent to abide by the cited regulation. This is a repeat citation therefore civil penalty in the amount of $1000 dollars has been issued, civil penalty will continue to accrue until plan of correction is submitted to the LPA. First citation issued on 11/2/2021.

SUPERVISOR'S NAME: Eva Miller TELEPHONE: (818) 596-4373 LICENSING EVALUATOR NAME: Yelena Avetisyan TELEPHONE: (818) 378-8120 LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2022

Document Has Been Signed on 05/10/2022 06:34 PM - It Cannot Be Edited

FACILITY NAME: VELVET CARE	FACILITY NUMBER: 197610143
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/10/2022

Type A

Section Cited

CCR

80072(a)(7)

: (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (7) Not to be locked in any room, building, or facility premises by day or night. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by locking exterior perimeter gates and blocking exit door in room # 2 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/11/2022
	Plan of Correction
1 2 3 4	Licensee/Administrator will conduct a training for all direct care regarding the cited regulation. Proof of training will be provided to LPA. A prior citation was issued on 1/6/2022 by LPA A. Pitz. The licensee/administrators failed to submit the plan of correction.

Type A

Section Cited

CCR

87307(d)(6)

Personal Accommodations and Services. (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation made during the physical plant tour, the licensee did not comply with the section cited above by failing to ensure exit door in Rm # 2 is clear from obstruction by placing bed in front of the exit door which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/10/2022
	Plan of Correction
1 2 3 4	Administrator moved the bed during visit, deficiency cleared on site. Administrator will provide a signed statement of understanding and intent to abide by the cited regulation. This is a repeat citation therefore civil penalty in the amount of $250 dollars has been issued, civil penalty will continue to accrue until plan of correction is submitted to the LPA. First citation issued on 1/6/2022.

SUPERVISOR'S NAME: Eva Miller TELEPHONE: (818) 596-4373 LICENSING EVALUATOR NAME: Yelena Avetisyan TELEPHONE: (818) 378-8120 LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2022

Document Has Been Signed on 05/10/2022 06:34 PM - It Cannot Be Edited

FACILITY NAME: VELVET CARE	FACILITY NUMBER: 197610143
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/10/2022

Type A

Section Cited

CCR

87465(a)(1)

The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on medication review, the licensee did not comply with the section cited above in 2 out of 6 residents by not ensuring that medications were given as prescribed which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/11/2022
	Plan of Correction
1 2 3 4	Administrator will schedule vendorized medication training for all staff. Training will need to be scheduled within 24 hours and completed by 5/24/2022. A prior citation was issued on 11/23/2021 by LPA A. Pitz. The licensee/administrators failed to submit the plan of correction.

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services. Centrally stored medications shall be kept in a safe locked place that is not accessible to persons other than employees responsible for the supervision of the medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by storing/keeping the insulin in the kitchen refrigerator unlocked and accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/11/2022
	Plan of Correction
1 2 3 4	The Administrator will ensure all medications that need to be in the refrigerator are kept in a locked box in both refrigerators on the premises. A written declaration on how this will not be repeated again shall be submitted to LPA by POC date.

SUPERVISOR'S NAME: Eva Miller TELEPHONE: (818) 596-4373 LICENSING EVALUATOR NAME: Yelena Avetisyan TELEPHONE: (818) 378-8120 LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2022

Document Has Been Signed on 05/10/2022 06:34 PM - It Cannot Be Edited

FACILITY NAME: VELVET CARE	FACILITY NUMBER: 197610143
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/10/2022

Type A

Section Cited

CCR

87628(a)

The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interviews, the licensee did not comply with the section cited above by not ensuring diabetes medication and testing for 2 residents is performed themselves or an appropriately skilled professional which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/11/2022
	Plan of Correction
1 2 3 4	The licensee/administrator will submit a written statement how this deficiency will be corrected. The licensee/administrator will obtain vendorized training for themselves and all staff regarding the cited regulation. Proof of completed training will also need to be submitted as POC. A prior citation was issued on 11/30/2021 by LPA A. Pitz for which the plan of correction was not completed/submitted.

Type A

Section Cited

CCR

87625(b)(3)

Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation mad on 5/9/2022, the licensee did not comply with the section cited above by not ensuring R3 and Facility remained free of odors from incontinence which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/11/2022
	Plan of Correction
1 2 3 4	The licensee/administrator will submit a written statement how this deficiency will be corrected. The licensee/administrator will obtain vendorized training for themselves and all staff regarding the cited regulation. Proof of completed training will also need ot be submitted as POC. A prior citation was issued on 11/16/2021 by LPA A. Pitz for which the plan of correction was not completed/submitted.

SUPERVISOR'S NAME: Eva Miller TELEPHONE: (818) 596-4373 LICENSING EVALUATOR NAME: Yelena Avetisyan TELEPHONE: (818) 378-8120 LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2022

Document Has Been Signed on 05/10/2022 06:34 PM - It Cannot Be Edited

FACILITY NAME: VELVET CARE	FACILITY NUMBER: 197610143
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/10/2022

Type A

Section Cited

CCR

87412(a)(12

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General. 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 ensuring 3 out of 7 staff have a TB test on file which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/13/2022
	Plan of Correction
1 2 3 4	Licensee/Administrator will obtain TB test and current health screening for all staff. Copies of the health screenings will need to be submitted as POC.

Type A

Section Cited

CCR

87207

False Claims. No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on infromation provided to LPA he licensee did not comply with the section cited above in by providing LPA false statement regarding an individual observed at the facility during the 5/9/2022 visit and observed to be staff during today's visit. Additionally Staff member preent during today's visit provided a false name to the LPA.
	POC Due Date: 05/11/2022
	Plan of Correction
1 2 3 4	Administrator Naira Paroyan will provide a written explanation to the Department why she, Staff present during the 5/9/2022 and staff present during todays visit provided false information to the LPA.

SUPERVISOR'S NAME: Eva Miller TELEPHONE: (818) 596-4373 LICENSING EVALUATOR NAME: Yelena Avetisyan TELEPHONE: (818) 378-8120 LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2022

Document Has Been Signed on 05/10/2022 06:34 PM - It Cannot Be Edited

FACILITY NAME: VELVET CARE	FACILITY NUMBER: 197610143
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/10/2022

Type A

Section Cited

CCR

87405(d)(1-7)

87405(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	.The Applicant Representative and Administrator understand that the facility is being cited for Administrator Qualifications due to the Administrator exhibiting a lack of understanding and/or the inability to comply with applicable laws, rules and regulations including but not limited to Title 22 regulations as demonstrated during visits on 11/16/21, 11/23/21, 11/30/21, 1/6/22, 1/11/22, 5/9/22 and 5/10/22.
	POC Due Date: 05/10/2022
	Plan of Correction
1 2 3 4	The agreed upon plan of correction is as follows: Applicant Representative will advertise an opening for a certified administrator. Correct all deficiencies cited during the Annual Inspection and pending from other citation issued. Applicant Representative will submit a screen shot or copy of the job announcement, LIC 500 and staff schedule. Applicant Representative will also retain a weekly staff worked schedule at the facility to be reviewed by Department Staff as needed.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Eva Miller TELEPHONE: (818) 596-4373 LICENSING EVALUATOR NAME: Yelena Avetisyan TELEPHONE: (818) 378-8120 LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2022