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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610150
Report Date: 06/18/2024
Date Signed: 06/18/2024 02:18:26 PM


Document Has Been Signed on 06/18/2024 02:18 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:CALIFORNIA DREAM ASSISTED LIVINGFACILITY NUMBER:
197610150
ADMINISTRATOR:AGHABEKYAN, GAYANEFACILITY TYPE:
740
ADDRESS:7043 TAMPA AVETELEPHONE:
(818) 300-8393
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:6CENSUS: 4DATE:
06/18/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Rima Agaronyan, Administrator DesigneeTIME COMPLETED:
02:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Huma Rahimi conducted unannounced visit to this facility in conjunction with a complaint control #31-AS-20240611160853. LPA met with Staff #1 (S1) who granted access to facility. The Administrator Designee was contacted and LPA explained the reason for the visit.

During the visit, LPA was informed that on 03/30/2024, R1 had inflammation of the skin around the right foot toenails and R1 was taken to the hospital. On 04/29/2024, R1 was taken to the hospital again for the inflammation of the skin around the right foot toenails. Additionally, on 05/09/2024, R1 was taken to the hospital for the inflammation of the toenail not getting better and R1 being in pain. However, no incident reports were submitted to the Community Care Licensing Department (CCLD) in a timely manner. LPA reviewed all incident reports on a system and did not observe any Incident Reports regarding R1. In addition, the Administrator admitted that no incident was submitted to the Regional Office (RO). Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPAs informed the Administrator that all staff members are mandated reporters and they are all responsible for reporting.

LPA informed the Administrator to submit an incident reports that occurred on or before :
  • 03/30/24, 04/29/2024, and 05/09/2024 (three incidents)

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is cited and noted on LIC 809D.

Exit interview conducted, appeal rights and copy of report signed and delivered.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024
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 2


Document Has Been Signed on 06/18/2024 02:18 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: CALIFORNIA DREAM ASSISTED LIVING
FACILITY NUMBER: 197610150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/18/2024
Section Cited
CCR
87211(a0(1)A,B&D

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Requirements
(a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)...
This requirement is not met as evidenced by:
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Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. R1's incident reports are provided at the time of the visit. POC cleared during the visit.
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Based on interviews and record reviews, conducted by LPA, the licensee did not comply with the section cited above by failing to notify CCLD regarding R1's hospitalization on or before 3/30/24, 2/29/24, and 5/9/24, which poses a potential health and safety 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: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024
LIC809 (FAS) - (06/04)
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