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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610248
Report Date: 11/01/2024
Date Signed: 11/01/2024 11:43:18 AM

Document Has Been Signed on 11/01/2024 11:43 AM - 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:VELVET CAREFACILITY NUMBER:
197610248
ADMINISTRATOR/
DIRECTOR:		PAROYAN, NAIRAFACILITY TYPE:
740
ADDRESS:15731 LEMARSH ST.TELEPHONE:
(818) 810-0074
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 6CENSUS: 6DATE:
11/01/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Naira Paroyan-AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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On 11.01.2024 in conjunction with an initial complaint visit control number 31-AS-20241031153253. Licensing Program Analyst (LPA) Leslie Ngo-Castaneda and Licensing Program Manager (LPM) Nichelle Gillyard completed an unannounced CASE MANAGEMENT- Deficiencies visit. LPA met with Licensee Naira Paroyan, explained the purpose of the visit.

During the facility tour at 10:01AM . LPA observe the following:
  • Storage of oxygen in the room was seen in bedroom #1 and bedroom #4 at 10:02 AM, but no oxygen sign was present in the bedrooms doors.
  • Window screens were broken in bedroom #1 located beside the television was observed at 10:02AM.
  • Medication for R4 was left on the kitchen counter in a plastic container at 10:13AM.
  • S3 is a new staff needs proper training before starting working at the facility.
  • LPM and LPA observed video footage has audio and showed bedroom #1 and 3, residents rights were violated.



Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiency was observed and cited (Refer to LIC 809-D).

Copy of this report provided, appeal rights given. Exit interview conducted.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/01/2024 11:43 AM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 11/01/2024 at 10:34 AM
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: VELVET CARE
FACILITY NUMBER: 197610248

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2024
Section Cited
CCR
87618(b)(3)(b)

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Ensuring that the use of oxygen equipment meets the following requirements: "No Smoking-Oxygen in Use" signs shall be posted in the appropriate areas.This requirement is not met as evidenced by: LPA and LPM did not observe 'oxygen in use' sign.
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Administrator needs to post a 'No Smoking-Oxygen in Use" sign on the bedroom door.
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This poses a potential health and safety risk to residents in care.
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Type B
11/15/2024
Section Cited
CCR87303(a)

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Maintenance and operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met.
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Administartor needs to ensure that screens located within the facility are clean and in good repair.
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 as evidenced by: LPA and LPM observed the facility screen was in disrepair. This poses a potential health and safety risk to residents 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 Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/01/2024 11:43 AM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 11/01/2024 at 10:58 AM
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: VELVET CARE
FACILITY NUMBER: 197610248

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/02/2024
Section Cited
CCR
87465(h)(2)

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Incidental medical and dental Care: The following requirements shall apply to medications which are centrally stored:Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the medication.
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Staff needs to lock and store medication of residents. POC was done during today with administrator. Medication was stored and lock away in the locked medicine cabinet.
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supervision of the centrally stored. This requirement is not met by staff leaving a pill in a covered cup for R4 in the kitchen counter that is accessible to the residents in the facility. This poses a potential health and safety risk to residents in care.
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Type B
11/03/2024
Section Cited
HSC1569.925(b)(1)

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(b) (1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff
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Administrator needs to ensure S3 has the proper vendor training before working at the facility. Administrator will email schedule of the training and upon completion or staff sign-in sheet with training material for all staff that assist with medication.
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member shall complete 20 hours... restricted health conditions, and hospice care... before working independently with residents. This was evident by LPM and LPA review of records for S3. This poses a potential health and safety risk to residents 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 Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/01/2024 11:43 AM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 11/01/2024 at 11:22 AM
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: VELVET CARE
FACILITY NUMBER: 197610248

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/08/2024
Section Cited
CCR
87468.2(a)(1)

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Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) to have a reasonable level of personal privacy in accommodations, medical treatment, personal care and
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Administrator will ensure that the camera surveillance does not have any audio and be reposition so that it would not look into bedroom #1 and bedroom #3. Administrator will be sending a certifcation that audio is off.
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... of resident and family groups. This requirement is not met as evidenced by: LPA and LPM did not observe camera surveillance to having audio and looking into S1 bedroom. This poses a potential health and safety risk to residents 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 Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2024


LIC809 (FAS) - (06/04)
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