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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610143
Report Date: 11/02/2021
Date Signed: 11/02/2021 02:51:31 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:
11/02/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jack BerghoudianTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Pitz generated this Case Management report to address additional deficiencies observed during an unannounced visit for complaint # 31-AS-20211027124121.

Upon arrival to the facility LPA was greeted by staff 1 (S1). LPA called the Woodland Hills Regional Office (WHRO) at 9:47am and confirmed that S1 is not associated to the facility and does not have any background clearance. S1 stated that they have been working at the facility for four weeks.

While touring the outside perimeter at 9:36 am LPA observed the fire exits on both sides of the facility to be locked with padlocks.

During a file review at 11:15 am LPA confirmed that there are four residents with dementia living at the facility. At 10:00 am S1 confirmed that there is no lock for the door leading to the garage from the kitchen, and there is no lock on the staff room. At 10:07am LPA observed the unlocked garage to contain numerous hazardous chemicals such as bleach and other cleaning agents.

At 11:00am LPA confirmed with administrator that Resident 1 (R1) fell and cut their head approximately two weeks ago and Resident 2 (R2) fell and hit their head on 10/31/21. Administrator stated that 911 was called for R1's fall, but not for R2's, and that neither fall was reported to Community Care Licensing.

While reviewing client records at 11:15am LPA observed R2, Resident 3 and Resident 4 to have diagnosis of dementia with physicians reports and appraisals that are over one year old.

Report reviewed, signed and delivered. Exit interview conducted, deficiencies and civil penalties cited on 809D page
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
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 4
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: 11/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/02/2021
Section Cited

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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
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This requirement is not met as evidenced by:

Based on inteviews and records reviewed, the facility did not ensure that S1 had a criminal record clearance on file before working at the facility which poses an immediate risk to residents in care.
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Type A
11/02/2021
Section Cited

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(l) 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
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This requirement is not met as evidenced by:

Based on observations and file review, the facility did not ensure that it had the appropriate fire clearance before locking the property's gated perimeter fence which poses an immediate risk to the 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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: 11/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/02/2021
Section Cited

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87705(f)(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
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Based on observations and record review, the facility did not ensure that dangerous cleaning agents were kept inaccessible to residents with dementia which poses an immediate risk to residents in care.
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Type A
11/02/2021
Section Cited

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87465(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).
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This requirement is not met as evidenced by:

Based on observations and interviews, the facility did not call 911 when R2 fell and hit their head on 10/31/21 which poses an immediate risk to 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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4
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: 11/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/09/2021
Section Cited

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(87211(a)(1)B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.


This requirement is not met as evidenced by:
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Based on interviews and observations, R1 fell approximately two weeks ago and R2 fell on 10/31/21 and neither incident was reporte to CCL which poses an immediate risk to the residents in care.
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Type A
11/09/2021
Section Cited

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87705(c)(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
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This requirement is not met as evidenced by:

Based on a file review, the facility did not ensure that residents with dementia had an annual medical assessment on file whic hposes an immediate risk to 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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4