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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610162
Report Date: 09/21/2023
Date Signed: 09/21/2023 01:18:04 PM


Document Has Been Signed on 09/21/2023 01:18 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:LOVE & CARE SENIOR LIVING, INC.FACILITY NUMBER:
197610162
ADMINISTRATOR:PASCO, DINAH RFACILITY TYPE:
740
ADDRESS:17710 MARTHA STREETTELEPHONE:
(818) 585-0063
CITY:ENCINOSTATE: CAZIP CODE:
91316
CAPACITY:6CENSUS: 6DATE:
09/21/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Nat and Ramon BarronTIME COMPLETED:
01:20 PM
NARRATIVE
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At 11:30 a.m. on 09/21/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with Staff #1 (S1) and Staff #2 (S2) and disclosed the reason for the visit. LPA called the licensee at 12:45 p.m.

LPA Melissa Ruiz conducted a complaint visit and a case management visit to the facility at 10:00 a.m. on 08/08/2023 to address an allegation from complaint #31-AS-20230801134042 and facility deficiencies. LPA Ruiz substantiated the allegation “Staff did not provide resident adequate supervision resulting in resident leaving the facility unsupervised” and addressed deficiencies related to the change of facility ownership and reporting requirements.

Today, LPA interviewed S1 and S2 between 11:45 a.m. and 12:45 p.m., called the new applicant at 12:50 p.m., interviewed Resident #1 (R1) at 1:00 p.m., and reissued the deficiencies from the 08/08/2023 complaint and case management visits with a new Plan of Correction due date on the attached LIC 809-D page.

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

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023
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 09/21/2023 01:18 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: LOVE & CARE SENIOR LIVING, INC.
FACILITY NUMBER: 197610162

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/02/2023
Section Cited
CCR
87705(b)(2)

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87705 Care of Persons with Dementia
(b) In addition to... Section 87208... the plan of operation shall address... (2) Safety measures to address... wandering, aggressive behavior and ingestion of toxic materials. This requirement is not met as evidenced by:
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Licensee is to generate a Resident Reappraisal for Resident #1 that addresses behaviors including but not limited to wandering from the facility without assistance and their care plan to reflect those behaviors.
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Based on interviews, the licensee did not comply with the section cited above in 1 out of 6 residents which poses an immediate Health, Safety, or Personal Rights risk of 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 MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 09/21/2023 01:18 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: LOVE & CARE SENIOR LIVING, INC.
FACILITY NUMBER: 197610162

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/02/2023
Section Cited
HSC
1569.191(b)(2)

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§1569.191 Sale of licensed facility... (b) Except as provided... business shall not be transferred until the buyer qualifies for a license ... (2) The prospective buyer shall submit an application for a license... within five days. This requirement is not met as evidenced by:
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The Licensee and the new applicant/buisness owner shall submit a Change of Ownership application by the POC due date. Furthermore, moving forward the licensee shall abide by HSC 1569.191, and document this on a written statement.
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Based on interviews and record review, the licensee did not comply with the section cited above in 1 out of 1 transfers, which poses a potential Health, Safety, or Personal Rights risk to persons in care.
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Type B
10/02/2023
Section Cited
CCR87211(a)(1)(D)

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87211 Reporting Requirements (a) Each licensee shall furnish...(1) A written report ... to the licensing agency and to the person responsible... within seven days ... (D) Any incident which threatens... any resident.
This requirement is not met as evidenced by:
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The licensee and all staff shall participate in a training pertaining to this regulation. Proof of training shall be submitted by the POC due date.
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Based on interview and record review, the Licensee did not comply with the section cited above in 1 out of 1 incident reports, which poses a potential 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 MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3