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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610144
Report Date: 12/20/2023
Date Signed: 12/20/2023 03:56:02 PM

Document Has Been Signed on 12/20/2023 03:56 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:VICTORIA'S DIGNITY CAREFACILITY NUMBER:
197610144
ADMINISTRATOR:BERGHOUDIAN, JACK JFACILITY TYPE:
740
ADDRESS:13874 KELOWNA ST.TELEPHONE:
(818) 894-5761
CITY:ARLETASTATE: CAZIP CODE:
91331
CAPACITY: 6CENSUS: 5DATE:
12/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Jack BerghoudianTIME COMPLETED:
03:55 PM
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At 8 :00 a.m. on 12/20/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced subsequent complaint visit for complaint # 31-AS-20230821153401. LPA met with Staff #1 (S1) and later the administrator at approximately 8:30 a.m. and disclosed the reason for the visit.

During the course of investigation, other deficiencies were discovered in the facility. Therefore, this case management visit was conducted to address the deficiencies discovered.

During a record review at 8:15 a.m. today, it was discovered that Resident #1 (R1) and Resident #2 (R2) were enrolled in hospice services on 07/07/2023 and 06/21/2023. The plans of care were signed by a registered nurse, a medical social worker, a spiritual counselor, and a medical director, but were not signed by the licensee, R1, R2, or their responsible parties. This deficiency is cited on the attached LIC 809-D page.

Records detailing facility personnel duties, hospice visits, and personnel trainings were not maintained or included in hospice records in the facility. Resident #3 (R3) and Resident #4 (R4) are enrolled in hospice services but did not have hospice care plans maintained in the facility. The administrator contacted the hospice agency for the care plans at 9:00 a.m. today. This deficiency is cited on the attached LIC 809-D page.

Roommate acknowledgements of hospice services for R1, R2, R3, and R4 were not maintained or available at the facility. This deficiency is cited on the attached LIC 809-D page.

Exit interview conducted. Appeal rights discussed. Copy of report provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2023
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 3
Document Has Been Signed on 12/20/2023 03:56 PM - It Cannot Be Edited


Created By: Nicholas Reed On 12/20/2023 at 02:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VICTORIA'S DIGNITY CARE
FACILITY NUMBER: 197610144

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/29/2023
Section Cited
CCR
87633(a)(4)

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87633 Hospice Care of Terminally Ill Residents (a) The licensee shall... (4) A written hospice care plan ... is developed for each terminally ill resident ... by that resident’s hospice agency and agreed to by the licensee and the resident. This requirement was not met as evidenced by:
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Licensee to obtain signatures on care plans and submit proof by the POC due date.
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Based on record review, the licensee did not comply with the section cited above in two (02) out of five (05) residents which poses a Health, Safety, or Personal rights risk to persons in care.
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Type B
12/29/2023
Section Cited
CCR87633(a)(6)

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87633 Hospice Care of Terminally Ill Residents (a) The licensee shall ...
(6) The hospice agency and the resident... agree to provide the licensee with all information necessary to allow the licensee to comply with all regulations.This requirement is not met as evidenced by:
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Licensee to obtain complete care plans and related documents and submit proof by the POC due date.
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Based on record review, the licensee did not comply with the section cited above in two (02) out of five (05) residents 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:Naira Margaryan
LICENSING EVALUATOR NAME:Nicholas Reed
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/20/2023 03:56 PM - It Cannot Be Edited


Created By: Nicholas Reed On 12/20/2023 at 02:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VICTORIA'S DIGNITY CARE
FACILITY NUMBER: 197610144

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/29/2023
Section Cited
CCR
87633(h)(5)

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87633 Hospice Care of Terminally Ill Residents (h) For each terminally ill resident...(5) A statement signed by the resident's roommate... indicating his or her acknowledgment. This requirement is not met as evidenced by:
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Licensee to obtain roomate acknowledgements and maintain them in the faiclity files. Proof of correction due by POC due date.
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Based on record review, the licensee did not comply with the section cited above in four (04) out of five (05) residents 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:Naira Margaryan
LICENSING EVALUATOR NAME:Nicholas Reed
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023


LIC809 (FAS) - (06/04)
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