<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610269
Report Date: 06/11/2024
Date Signed: 06/11/2024 05:32:45 PM


Document Has Been Signed on 06/11/2024 05:32 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.RO, 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: 4DATE:
06/11/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Oleg Markiv-caregiverTIME COMPLETED:
05:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
This Case Management visit is conducted in conjunction with complaint investigation visit conducted today. (Complaint 31-AS-20240605130632). The purpose of this Case Management visit is to address the deficiencies that were observed during the complaint investigation not related to the complaint. LPA greeted by the staff #1 (S1) who identified himself as a caregiver for the facility. LPA explained the reason for the visit and requested the caregiver to inform the Administrator about Licensing Visit. S1 provided their names and LPA Dela Cerra noted that S1 did not have a criminal record clearance and association to the facility.
In addition, upon further review of recent licensing reports, LPA noted that during Case management visit conducted by the Department on 05/21/2024, the facility was cited for allowing a same individual, S1 to work in the facility without criminal record clearance and association.
In addition, while reviewing residents’ records, LPA observed that the records were not complete and/or current.
As per history of facility licensing reports, the Administrator of record is never present at the facility and Licensing representatives were greeted either by the designee or by the caregivers.

LPA De La Cerra contacted the Administrator over the phone and informed that at the time of this visit the facility will be cited for the following Title 22 Deficiencies. During the investigation and record review, LPA observed the following:

CONTINUED to LIC809-C
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Leizl De La CerraTELEPHONE: (818) 454-0632
LICENSING EVALUATOR SIGNATURE:
DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2024
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 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HOUSE OF HOPE ASSISTED LIVING, INC
FACILITY NUMBER: 197610269
VISIT DATE: 06/11/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
· On 5-21-2024 the facility was in violation of CCR 87355(e)(1) and was issued a citation. S1’s name is identified as the individual in violation on the LIC421BG form.
At the time of this visit S1 is still present at the facility without obtaining criminal record clearance and association. In addition to the citation $3,000.00 will be issued to the facility.
· R1's and other residents facility files/records are incomplete.
· Facility Administrator does not have required qualifications and is not present in the facility as required by Title 22 Regulations.

Therefore, Pursuant to the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were cited and recorded on LIC809D.
The Administrator was informed over the phone that the staff present at the facility without criminal record and association must be removed from the facility as soon as possible.

No other immediate health and safety hazard is noted during this visit.
Exit interview was conducted, the report was signed by the facility staff. However, due to absence of the Administrator a copy of report will be delivered via e-mail.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Leizl De La CerraTELEPHONE: (818) 454-0632
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/11/2024 05:32 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.RO, 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: 06/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/25/2024
Section Cited
CCR
87506

1
2
3
4
5
6
7
Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility….readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by;
1
2
3
4
5
6
7
Administrator shall complete the Resident Records records for all residents in care and submit proof to CCL/LPA by POC due date. POC due date 6/25/2024.
8
9
10
11
12
13
14
Licensee did not ensure to maintain complete and current records for facility residents. This posses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
Type B
06/25/2024
Section Cited
CCR87405

1
2
3
4
5
6
7
Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) to (7)... all requirements apply. (2) Knowledge of & ability to conform to the applicable laws...This requirement is not met as evidenced by.
1
2
3
4
5
6
7
The administrator will enroll and take more administrator courses and provide proof that training courses are secured and submit proof to CCL/LPA by POC due date. POC due date 6/25/2024.
8
9
10
11
12
13
14
The Licensee failed to follow Title 22 Regulations regarding staffing requirements. This posses a potential health and safety risk
to residents in care.
8
9
10
11
12
13
14
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: Leizl De La CerraTELEPHONE: (818) 454-0632
LICENSING EVALUATOR SIGNATURE:
DATE: 06/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 06/11/2024 05:32 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.RO, 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: 06/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/12/2024
Section Cited
CCR
87355(f)(1)

1
2
3
4
5
6
7
Criminal Clearance (f) Violation of Sec. 87355(e) shall result in an immediate... civil penalties(1)Subsequent violations within a twelve (12) mo. period will result in a civil penalty ($100)a day for a max of thirty 30 days.This requirement is not met as evidenced by
1
2
3
4
5
6
7
LPA requested admin to remove S1 from facility asap. Within 24 hours licensee must inform RO that S1 is removed and will not return to facility without criminal record clearance and association.
A $3,000,00 civil penalty will be assed at the time of this visit.
8
9
10
11
12
13
14
Licensee failed to obtain criminal record association for S1. This is the second 2nd offense for S1.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Leizl De La CerraTELEPHONE: (818) 454-0632
LICENSING EVALUATOR SIGNATURE:
DATE: 06/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4