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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610143
Report Date: 11/09/2021
Date Signed: 11/09/2021 03:45:23 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: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:
11/09/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jack BerghoudianTIME COMPLETED:
03:30 PM
NARRATIVE
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This report was generated in order to address deficiencies and issue civil penalties from issues that were observed and documented on 11/2/21.

On 11/2/21 the facility was cited under 87411(a) for a lack of staffing that resulted in at least two resident injuries.

On 11/2/21 the facility was cited for 6 type A citations in a case management visit and two complaint allegations were substantiated. The administrator demonstrated a lack of understanding of licensing regulations.

Report reviewed, signed and delivered. Exit interview conducted, deficiencies cited and appeal rights given.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
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: VELVET CARE
FACILITY NUMBER: 197610143
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/29/2021
Section Cited

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87405(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the...
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This requirement is not met as evidenced by:

Based on the citations issued on 11/2/21 and the NonCompliance conference held on 11/9/21 the administrator did not ensure that they were qualified and present at the facility enough to ensure its compliance with licensing regulations.
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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: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2