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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610318
Report Date: 01/09/2024
Date Signed: 01/09/2024 02:25:35 PM


Document Has Been Signed on 01/09/2024 02:25 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:EMERALD SENIOR CARE,INC.FACILITY NUMBER:
197610318
ADMINISTRATOR:HAYRAPETYAN, ELENFACILITY TYPE:
740
ADDRESS:10401 ENCINO AVE.TELEPHONE:
(747) 300-2232
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:6CENSUS: 6DATE:
01/09/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Hayk Margaryan-AdministratorTIME COMPLETED:
02:30 PM
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In conjunction with a Case Management (CM) for the previous facility number, #197609862 (see LIC 809 dated 01/09/24-closed/change of ownership, Licensing Program Analyst (LPA) Michael Cava conducted a Case Management (CM) visit for an incident that occurred the same day (01/09/24) at the current facility license number (197610318). During the CM visit, Resident 1 (R1) had a fall. As a result, R1 was experiencing and complaining of pain. Family member and hospice nurse was present. According to the hospice nurse, hospice protocol for the facility is to notify the hospice agency first, if incident is non-emergency and non-life threatening. Nurse made their assessment, and incident is not considered life threatening and/or non-emergency. Nurse stated, non-emergency medic was called and they are awaiting their arrival for further assistance. LPA questioned the administrator on why 911 was not notified. Administrator stated, the last time emergency paramedics were called, paramedics were upset at him, asking him why he did not adhere to R1's hospice care plan, and advised them to refer to R1's hospice care plan for non-immediate emergency. Per administrator, this is only R1's second fall since being admitted. R1 has no history of falls. LPA advised administrator to submit an Incident Report (IR) to the Licensing Agency to satisfy their reporting requirements. No citations issued at this time as facility appears to adhere to R1's hospice plan, and to provide R1 with the assistance they need.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024
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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