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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610143
Report Date: 11/30/2021
Date Signed: 11/30/2021 03:26:14 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: 5DATE:
11/30/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Jack BerghoudianTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Pitz conducted an unannounced Case Management/POC visit to address additional concerns observed during a complaint investigation visit on this day.

LPA issued a civil penalty for failure to correct a citation issued on 11/16/21 for violating section 87411(a). As of 11/30/21, no professionally created incontinence or catheter care plans have been submitted to licensing, a plan of correction that was due on 11/17/21. Civil penalties assessed at $100/day for a total of $1400.

At 12:18 pm LPA observed Resident 1(R1), a client with dementia, to be sitting alone in the outside patio area where an unsecured circular saw was also left out. At 12:20pm LPA observed the cabinet under the kitchen sink, where potentially harmful chemicals/cleaning agents are stored, to be unlocked, as was the door to the garage where additional hazardous materials are stored.

At 12:37 pm LPA asked Staff 1 (S1) what R1's diagnosis were, and specifically if R1 had a diagnosis of dementia, to which S1 responded "I don't know, I am not a doctor." At 12:41pm LPA asked to see staff and client files and was told by S1 that they didn't know where the key was, or which records pertained to whom.

At 12:52pm administrator confirmed that there was no hospice file on site for Resident 2 (R2), and that no reappraisal had been performed by the facility prior to R2 being discharged from the hospital on 11/28/21 and returning to the facility on hospice.

At 12:56 pm administrator stated that there was no file present at the facility for staff 1 (S1), and that S1 had not yet completed their new employee training. At 12:15pm when LPA arrived at the facility, S1 was the only staff member present.
Report reviewed, signed and delivered. Exit interview conducted, deficiencies on 809D page. Civil penalties assessed for repeat violations.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021
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: 11/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/30/2021
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, the facility did not ensure that toxic cleaning supplies and dangerous tools were inaccessible to residents with dementia which poses an immediate risk to the health and safety of residents in care.
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Type A
12/01/2021
Section Cited

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87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance...
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This requirement is not met as evidenced by:

Based on staff interviews, S1 was unable to say what the diagnosis of R1 was and did not know how to access client records 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: 11/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2021
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: 11/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/30/2021
Section Cited

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(b) (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....
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This requirement is not met as evidenced by:

Based on observations and interviews, the facility did not ensure that S1 had completed and documented 20 hours of training prior to working independently with residents which poses an immediate risk to clients in care.
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Type A
12/01/2021
Section Cited

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87463(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:
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This requirement is not met as evidenced by:
Based on interviews and observations, the faciltiy did not ensure that a new appraisal was conducted for R2 before allowing R2 to return to the facility with a change in condition/ doctors orders 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: 11/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2021
LIC809 (FAS) - (06/04)
Page: 3 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: 11/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/07/2021
Section Cited

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87633(b) 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:
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Based on observations and interviews, the faciltiy did not ensure that a hospice care plan was kept at the facility for R2 which poses a potential risk to residents in care.
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Type B
12/07/2021
Section Cited

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87412(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

This requirement is not met as evidenced by:
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Based on observations and interviews, the facility did not ensure that a file was maintained at the facility for S1 which poses a potential 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: 11/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4