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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610143
Report Date: 06/08/2022
Date Signed: 06/08/2022 07:44:41 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/08/2022 07:44 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:VELVET CAREFACILITY NUMBER:
197610143
ADMINISTRATOR:BERGHOUDIAN, JACK JFACILITY TYPE:
740
ADDRESS:15731 LEMARSH ST.TELEPHONE:
(818) 891-9186
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 6DATE:
06/08/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Jack BerghoudianTIME COMPLETED:
07:30 PM
NARRATIVE
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An unannounced Annual Continuation visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. Upon arrival LPA met with staff Cynthia Sherriel.

Staff contacted administrators Jack Berghoudian and Naira Paroyan (also pending applicant) via telephone. Approximately 9:18 am LPA spoke with Mr. Berghoudian via telephone. Mr. Berghoudian informed LPA that he was busy today and did not expect the LPA's visit. LPA reminded him that the Department's visits are unannounced and requested that both he and Ms. Paroyan be present during the visit.

Approximately 9:39 am LPA spoke with Naira Paroyan who reported that she was unable to come to the facility due to a medical procedure she received. LPA discussed the pending POC's. LPA was holding while Ms. Paroyan contacted administrator J. Berghoudian. Staff then started speaking with Ms. Paroyan to locate the resident files then hung up. At 9:45 am LPA called Ms. Paroyan and continued discussion about POC's. LPA informed Ms. Paroyan that she would be issuing citations for the incomplete/missing POC's. Ms. Paroyan became angry, made inappropriate comments called the LPA a foul/vulgar word and hung up the home.


At 9:05 am LPA conducted a tour of the facility and observed the following.
Rm # 1 Strong Urine Smell
Rm # 2 R2 with postural support (Bed rail)
Rm # 3 Full bedrail
Rm # 4 1 bed with postural support (Bed rail)

Approximately 9:15 am LPA spoke with staff regarding R2. Per staff R2 requires staff perform all activities of daily living and requires re-positioning.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2022
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: VELVET CARE
FACILITY NUMBER: 197610143
VISIT DATE: 06/08/2022
NARRATIVE
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Approximately 9:55 am Administrator Jack Berghoudian arrived. From 10:00 am to 10:45 am LPA reviewed the submitted POC's with Mr. Berghoudian, discussed the incomplete and missing POC's.

From 11:00 am LPA conducted review of resident and staff file. While conducting review LPA observed the following:

Resident Files:
  • R1. Physicians report incomplete, missing page with the physicians signature. All other records incomplete or missing.
  • R2: Requires assistance with all activities of daily living, missing PRN authorization letter, bedridden, missing order for postural support. Previously on Home Health however no home health records available at the facility.
  • R3: Physicians report dated 2017, Resident has a Major Neurocognitive disorder. All resident records from Prior licensee/facility, missing PRN authorization letter. Resident receiving hospice services however licensee/applicant does not have hospice care plan, hospice visit records. Resident is from Brilliant Corners and licensees of prior license, current licensee and applicant have been receiving P&I funds for resident without keeping documentation, and without a surety bond.
  • R4: Physicians report dated 2017, Resident has a Major Neurocognitive disorder. All resident records from Prior licensee/facility, missing PRN authorization letter. Resident receiving hospice services however licensee/applicant does not have hospice care plan, hospice visit records.
  • R5: All documents not signed by resident/responsible party.
  • R6 Physicians Report Incomplete, resident receiving hospice services however licensee/applicant does not have hospice care plan, hospice visit records.

Staff Files:
  • 3 out of 6 staff missing health screening, TB
  • 3 out of 6 staff files incomplete.
  • 5 out of 6 staff do not have first aid CPR.
  • 5 out of 6 staff do not have any documented required annual training.
  • 5 out of 6 staff do not have required medication training.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 13
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: 06/08/2022
NARRATIVE
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Approximately 2:00 pm LPA spoke with Staff 1 regarding her work schedule, LPA attempted to speak with Staff 2 (S2) who is also the sole overnight staff. S2 . Staff member was unable to understand and respond to questions. LPA informed Mr. Berghoudian that S2 cannot be the only staff working as she will not be able to respond to resident or contact emergency services if/when needed.

The licensee, administrators and pending applicant failed to submit the complete Plan Of Corrections (POC's) for the following deficiencies.

87465 (a)(1): Verification of scheduled medication training and completion of medication training for all staff was not completed. A prior citation was issued on 11/23/2021 by LPA A. Pitz plan of corrections were not submitted at that time.

80072 (a)(7): Licensee/Applicant/administrators failed to provide training to staff regarding the cited regulation.

87628 (a): The licensee/administrator did not obtain vendorized training for themselves and all staff regarding the cited regulation. A prior citation was issued on 11/30/2021 by LPA A. Pitz plan of corrections were not submitted at that time.

87625 (b)(3): The licensee/administrator did not obtain vendorized training for themselves and all staff regarding the cited regulation. A prior citation was issued on 11/16/2021 by LPA A. Pitz plan of corrections were not submitted at that time.

87412 (a)(12): Licensee/Administrator failed to obtain TB test and current health screening for all staff.

Prior to the completion of the visit LPA was informed by Administrator Jack Berghoudian that he will be providing letter of resignation to the current licensee, pending applicant and the Department.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
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: VELVET CARE
FACILITY NUMBER: 197610143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/08/2022
Section Cited

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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:
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Based on interview and record review, the licensee did not comply with the section cited above retaining 1 bedridden residents in Rm #2 which does not have bedridden fire clearance which poses an immediate health, safety or personal rights risk to persons in care.
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This is a zero tolerance and repeat violation therefore civil penalty in the amount of $1000 has been issued. Civl Penalties will continue to accrue until POC is received.
Type A
06/09/2022
Section Cited

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(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (5) Residents who depend on others to perform all activities of daily living for them as set forth in Section 87459, Functional Capabilities.
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This requirement was not met as evidened by: Based on observation, record review and interview the licensee retained R2 at the facility with a prohibited health condition after being dicharged from hospice care wihtout submitting an exception request which poses an immediate health and safety risk to the resident 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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/08/2022 07:44 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: VELVET CARE
FACILITY NUMBER: 197610143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/10/2022
Section Cited

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As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means. (b) Written requests shall include, but are not limited to, the following:
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This requirement was not met as evidenced by: Based on record review the licensee did not comply with the cited sections by not submitting an exception Request to retain R2 which poses an immediate health and safety risk to the resident in care.
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Type A
06/09/2022
Section Cited

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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:
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Based on observation, the licensee did not comply with the section cited above by storing/keeping the insulin in the refrigerator in a lock box, however the lock was not secured. which poses an immediate health, safety or personal rights risk to persons in care.
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This is a repeat citation therefore civil penalty in the amount of $250.00 was issued. Civil penalty will continue to accrue until completed POC is received.
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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/08/2022 07:44 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: VELVET CARE
FACILITY NUMBER: 197610143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/09/2022
Section Cited

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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:
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Based on medication review conducted on 5/10/2022, 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.
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A prior citation was issued on 11/23/2021 and 5/10/2022. The licensee/administrators failed to submit the plan of correction.
Type A
06/09/2022
Section Cited

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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:
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Based on record review and interviews condcuted on 5/10/2022, 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.
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verification of the scheduled raining with the trainers credentials will need to be submitted as POC.

A prior citation was issued on 11/30/2021 and 5/10/2022 for which the plan of correction was not completed/submitted.
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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/08/2022 07:44 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: VELVET CARE
FACILITY NUMBER: 197610143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/09/2022
Section Cited

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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:
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Based on observation made on 5/9/2022 and during today's visit, the licensee did not comply with the section cited above by not ensuring facility areas remained free of odors from incontinence which poses an immediate health, safety or personal rights risk to persons in care.
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verification of the scheduled raining with the trainers credentials will need to be submitted as POC.
A prior citation was issued on 11/16/2021 and 5/10/2022 for which the plan of correction was not completed/submitted.
Type A
06/09/2022
Section Cited

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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:
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Based on record review conducted on 5/10/2022 and during todays visit, the licensee did not comply with the section cited above by not ensuring 3 out of 6 staff have a TB test on file which poses an immediate health, safety or personal rights risk to persons 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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2022
LIC809 (FAS) - (06/04)
Page: 7 of 13


Document Has Been Signed on 06/08/2022 07:44 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: VELVET CARE
FACILITY NUMBER: 197610143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/09/2022
Section Cited

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Licensees who accept & retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment, & a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
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Based on record review, the licensee did not comply with the section cited above by not ensuring 5 out of 6 residents diagnosed with Dementia had an annual medical assessment and reappraisal which poses a potential health, safety or personal rights risk to persons in care.
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Type A
06/13/2022
Section Cited

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Postural Supports. A written order from a physician indicating the need for postural support shall be maintained in the resident’s record. The licensing agency is authorized to require additional documentation if needed.

This requirement is not met as evidenced by:
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Based on observation and record review the licensee did not comply with the section cited above by utilizing half bed rails for 2 residents without a written order from the physician which poses a potential health, safety or personal rights risk to persons 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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2022
LIC809 (FAS) - (06/04)
Page: 8 of 13


Document Has Been Signed on 06/08/2022 07:44 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: VELVET CARE
FACILITY NUMBER: 197610143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/10/2022
Section Cited

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7
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
This requirement is not met as evidenced by:
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Based on record review which revealed that the licensee/administrator did not comply with the cited section by not maintaining complete records for 6 out of 6 residents which poses a potential health, safety or personal rights risk to persons in care.
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Type A
06/10/2022
Section Cited

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Incidental Medical and Dental Care Services: If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted..

This requirement is not met as evidenced by:
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Based on record review, the licensee did not comply with the section cited by not obtaining PRN authorization letters for six (6) out of six (6) residents, which poses/posed a potential health, safety or personal rights risk to persons 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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2022
LIC809 (FAS) - (06/04)
Page: 9 of 13


Document Has Been Signed on 06/08/2022 07:44 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: VELVET CARE
FACILITY NUMBER: 197610143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/10/2022
Section Cited

1
2
3
4
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6
7
Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement was not met as evidenced by:
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Based on record review, the licensee did not comply with the section cited above by not ensuring 5 out of 6 staff received first aid training which poses a potential health, safety or personal rights risk to persons in care.
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14
Type A
06/09/2022
Section Cited

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Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements:

This requirement is not met as evidenced by:
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Based on interview and record review, the licensee did not comply with the section cited above by not ensuring proper medication training was provided to all staff which poses a potential health, safety and personal rights risk to persons in care.
8
9
10
11
12
13
14
verification of the scheduled raining with the trainers credentials will need to be submitted as POC.
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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/08/2022 07:44 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: VELVET CARE
FACILITY NUMBER: 197610143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/10/2022
Section Cited

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(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training.
This requirement is not met as evidenced by:
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Based on record review, the licensee did not comply with the section cited above by not ensuring staff receive the required training, which poses a potential health, safety or personal rights risk to persons in care.
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verification of the scheduled training with the trainers credentials will need to be submitted as POC.

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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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2022
LIC809 (FAS) - (06/04)
Page: 11 of 13


Document Has Been Signed on 06/08/2022 07:44 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: VELVET CARE
FACILITY NUMBER: 197610143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/10/2022
Section Cited

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A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: This requirement is not met as evidenced by:

This requirement is not met as evidenced by:
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Based on record review, the licensee did not comply with the section cited above by not maintaining a hospice care plan for 3 out of 3 residents who are currently on hospice which poses a potential health, safety or personal rights risk to persons in care.
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Type A
06/10/2022
Section Cited

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(a) Each licensee, other than a county, who is entrusted to safeguard resident cash resources, shall file, or have on file with the licensing agency a copy of a bond issued by a surety company to the State of California as principal. The amount of the bond shall be in accordance with the schedule listed under this regulation.
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This requirement was not met evidenced by: Based on record review and interview the licensee did not comply with the cited section by not obtaining a surety Bond prior hndling P&I for R3 which poses a health, safety or personal rights risk to persons 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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2022
LIC809 (FAS) - (06/04)
Page: 12 of 13


Document Has Been Signed on 06/08/2022 07:44 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: VELVET CARE
FACILITY NUMBER: 197610143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/10/2022
Section Cited

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Safeguards for Resident Cash, Personal Property, and Valuables. (b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources
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This requirement is not met as evidenced by:
Based on record review and interview conducted the licensee did not comply with the cited section by not distributing P & I funds to resident (R1), and not keeping proper records of funds entrusted to her which posed a personal rights violation to residents in care.
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Type A
06/10/2022
Section Cited

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87470(c) Infection Control Requirements shall be developed by the licensee... (1) The Infection Control Plan shall include: (F) Staff shall demonstrate knowledge... appropriate to the job assigned and as evidenced by safe and effective job performance. This requirement was not met as evidenced by:
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Based on observations the licensee/staff did not comply with the cited section by not screening LPA and other visitors for symptoms of COVID 19 upon entry and staff were not wearing masks, which poses and immediate Health and Safety and personal rights risk to persons in care.
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Training will need be scheduled by 6/10/2022 and completed by 6/20/2022 Proof of training and designation of staff shall be emailed to LPA no later than 06/20/22
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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2022
LIC809 (FAS) - (06/04)
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