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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610215
Report Date: 01/10/2022
Date Signed: 01/10/2022 12:40:25 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:BAHAMA ASSISTED LIVING, INCFACILITY NUMBER:
197610215
ADMINISTRATOR:AVOYAN, MARIETAFACILITY TYPE:
740
ADDRESS:15851 BAHAMA STREETTELEPHONE:
(747) 236-7322
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 4DATE:
01/10/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Karine SarkisyanTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Pitz conducted a scheduled prelicensing visit on this day.

LPA arrived at the facility and was greeted by staff. LPA utilized the RCFE Prelicensing Inspection tool to review all eleven inspection domains. The following issues to be corrected were identified:


-Resident 1 (R1) did not have a resident file present. Facility needs to provide proof of either a complete resident file being created for R1, or R1 being appropriately relocated from the facility.


Component III was conducted during the visit.

This report will be sent to the Centralized Application Bureau (CAB) You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB analyst. Failure to comply could affect approval of your license.


Report reviewed, signed and delivered. Exit interview conducted, deficiency on 809 D page.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022
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
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: BAHAMA ASSISTED LIVING, INC
FACILITY NUMBER: 197610215
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the facility did not ensure that R1 had a complete file on record.
POC Due Date: 01/17/2022
Plan of Correction
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Administrator will inform LPA of their plan to either retain their resident or ensure that they are appropriately relocated.
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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2022
LIC809 (FAS) - (06/04)
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