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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610177
Report Date: 07/19/2024
Date Signed: 07/19/2024 04:45:19 PM

Document Has Been Signed on 07/19/2024 04:45 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:ANNA'S HOME & PARADISEFACILITY NUMBER:
197610177
ADMINISTRATOR/
DIRECTOR:		ARMENYAN, ANNAFACILITY TYPE:
740
ADDRESS:23463 HAYNES STTELEPHONE:
(323) 660-0001
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY: 6CENSUS: 5DATE:
07/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Anna MalkhasyanTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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At approximately 9:15 a.m. on 07/19/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and later the administrator and disclosed the reason for the visit.

The facility was last visited on 11/22/2022 for a complaint visit. It is a single story building with five (05) bedrooms, two (02) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents, of which one (01) may be bedridden in Bedroom #5. The facility serves residents with dementia. Approved hospice waivers for six (06).

A file review was conducted prior to today’s visit. It was observed that the licensee corporation is in good standing with the Secretary of State but in “not good” standing with the Franchise Tax Board and was suspended on 07/01/2024.

At the main entrance, LPA observed a screening station for infectious diseases which contained masks, sanitizer, a digital thermometer, and a visitor sign-in sheet. Postings were observed at the front for the infection control plan, emergency disaster plan, personal rights, house rules, rights of resident councils, non discrimination notice, emergency contacts, theft and loss policy, ombudsman contacts, confidential complaint contacts, facility sketch with emergency exit routes clearly labelled, administrator certificate, facility license, and COVID postings.

Walls, floors, windows, screens, and blinds were clean and in good repair. The living room at the front contained furniture in good repair, television, reading material, an appropriately-grated fireplace, and a house telephone. The dining room contained a piano, board games, television, and furniture in good repair. Surveillance cameras were noticed and indicated in common areas. A sufficient supply of linens and towels were located in the hallway.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2024
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 5
Document Has Been Signed on 07/19/2024 04:45 PM - It Cannot Be Edited


Created By: Nicholas Reed On 07/19/2024 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: ANNA'S HOME & PARADISE
FACILITY NUMBER: 197610177

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
...(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews, the licensee did not comply with the section cited above in five (05) out of five (05) bedrooms which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2024
Plan of Correction
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Licensee has removed all auditory alarms on bedroom doors during the visit. Deficiency cleared.
Type B
Section Cited
CCR
87208(a)(7)(1)
87208 Plan of Operation (a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval... (7) Sketches, showing dimensions, of the following:
(A) Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended and a designation of the rooms to be used\
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in one (01) out of (01) facility sketch which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2024
Plan of Correction
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Licensee has agreed to remove the wall in Bedroom #5 so that the facility sketch does not need to be updated.
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: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 07/19/2024 04:45 PM - It Cannot Be Edited


Created By: Nicholas Reed On 07/19/2024 at 04:19 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: ANNA'S HOME & PARADISE
FACILITY NUMBER: 197610177

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(j)
87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in two (02) out of three (03) auditory alarns which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2024
Plan of Correction
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Licensee has agreed to submit a written statement regarding the deficient practice by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 07/19/2024 04:45 PM - It Cannot Be Edited


Created By: Nicholas Reed On 07/19/2024 at 04:24 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: ANNA'S HOME & PARADISE
FACILITY NUMBER: 197610177

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
87305 Alterations to Existing Building or New Facilities
(a) Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based oninterview, the licensee did not comply with the section cited above in the wall in Bedroom #5 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2024
Plan of Correction
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Licensee has agreed to remove the wall in Bedroom #5 and submit photographic proof by POC due date
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024


LIC809 (FAS) - (06/04)
Page: 5 of 5
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: ANNA'S HOME & PARADISE
FACILITY NUMBER: 197610177
VISIT DATE: 07/19/2024
NARRATIVE
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At approximately 9:15 a.m. LPA observed a fully charged fire extinguisher in the kitchen. It was purchased on 02/11/2024. At 9:25 a.m. LPA observed a fully-stocked first aid kit near the office area. Confidential files were also locked in the office area. The garage was locked and contained medications, an extra refrigerator, cleaning supplies, and other extra supplies. At 9:35 a.m. LPA measured the room temperature to be 74 degrees Fahrenheit.

Bedroom #5 is cleared for a bedridden resident. At approximately 9:40 a.m. LPA observed a constructed wall in the middle of Bedroom #5 creating two separate bedrooms. An updated facility sketch was not submitted to Community Care Licensing. This deficiency is cited on the attached LIC 809-D page. The auditory alarms on the exits of Bedroom #5 and the dining room were turned off during the visit. This deficiency is cited on the attached LIC 809-D page. Auditory alarms were observed on the bedroom doors of Bedroom #1, Bedroom #2, Bedroom #3, and Bedroom #4. LPA interviewed residents between 9:30 a.m. and 10:30 a.m. Three (03) out of five (05) residents stated the auditory alarms are turned on at night and disturb their comfort. This deficiency is cited on the attached LIC 809-D page. All bedrooms contained a lamp, a chair, nightstand, and a bed with adequate bedding. All furnishings were clean and in good condition.

The facility has two (02) bathrooms. One (01) bathroom is private to Bedroom #1, and one (01) is shared. All bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight-fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 9:50 a.m. LPA measured the water temperature in the private bathroom to be 114.4 degrees Fahrenheit.

LPA observed an adequate supply of perishable and non-perishable foods in the kitchen. The stove hood was clean. Appliances were in good condition. Sharps were locked below the counter top. Cleaning solutions and medications were locked in the garage. Detergents were locked above the laundry area. A washing machine and dryer were located near the kitchen. Both were in working order.

LPA observed a covered patio area in the rear of the facility. The patio contained furniture in good condition. At approximately 10:30 a.m., smoke and carbon monoxide detectors were tested and operational. Detectors were hard-wired and operated simultaneously. Two (02) out of two (02) fire doors closed when the detectors were tested. All emergency exit paths were free from obstructions. The exit gate was unlocked. Evacuation routes were posted.

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

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
LIC809 (FAS) - (06/04)
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