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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610269
Report Date: 02/15/2024
Date Signed: 02/15/2024 06:34:18 PM


Document Has Been Signed on 02/15/2024 06:34 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:HOUSE OF HOPE ASSISTED LIVING, INCFACILITY NUMBER:
197610269
ADMINISTRATOR:ALABERKYAN, GAYANEFACILITY TYPE:
740
ADDRESS:9617 STANWIN AVENUETELEPHONE:
(818) 302-6344
CITY:ARLETASTATE: CAZIP CODE:
91331
CAPACITY:6CENSUS: 2DATE:
02/15/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Galina JucovscaiaTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst, Melissa Spaeth, conducted an unannounced complaint visit regarding Complaint #31-AS-20240214144751 and Complaint #31-AS-20240214113238. LPA Spaeth was greeted by the caregiver who called the Administrator, Gayane Alaberkyan who stated they were unavailable.

LPA requested to see the resident files. The Administrator stated the files were locked in the Administrator's office and the Administrator could not come to the facility to unlock the office.

LPA and the caregiver toured the facility at 1:00 until 1:15 pm. At 1:00 pm, LPA observed a needle sitting on the kitchen table. LPA explained the needle should not be sitting out in the open and the caregiver disposed of the needle. The caregiver opened the medication cabinet and stated the lock was broken. LPA observed the medications were not properly locked in the cabinet.

Based upon Title 22 Regulations, the following deficiencies are substantiated. (See 809-D page).

Exit interview conducted, appeal rights discussed, and a copy of the signed report was given.

SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
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 02/15/2024 06:34 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: HOUSE OF HOPE ASSISTED LIVING, INC
FACILITY NUMBER: 197610269

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/16/2024
Section Cited
CCR
87755(c)

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87755 Inspection Authority of the Licensing Agency (c) The licensing agency shall have the authority to inspect, audit, & copy resident or facility records upon demand ...

This requirement was not met as evidenced by:
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The Administrator will send copies of the residents' records to LPA Spaeth via email to melissa.spaeth@dss.ca.gov by tomorrow monring, February 16, 2024.
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Based upon LPA's conversation with the Administrator, the resident records are locked in the administrator's office. The Administrator stated staff do not have access to the records.
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Type A
02/15/2024
Section Cited
CCR87465(h)(2)

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87465 Incidental Medical & Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe & locked place that is not accessible to persons other than employees......This requirement was not met as evidenced by:.
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During LPA's visit, the needle was removed from the premises. The caregiver stated the lock was broken to the medication cabinet. LPA spoke to the Adminstrator the lock must be replaced by tomorrow, 2/15/2024. The Administrator will send a snapshot of the new lock to LPA Spaeth
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Based on LPA's observation a needle was sitting on the kitchen table, and the medications were not safely locked in a cabinet. Staff did not comply with the section cited above which poses a potential health, safety & personal rights 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: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
LIC809 (FAS) - (06/04)
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