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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197610356
Report Date:
03/28/2024
Date Signed:
03/29/2024 11:20:01 AM
Document Has Been Signed on
03/29/2024 11:20 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:
BELOVED LIVING
FACILITY NUMBER:
197610356
ADMINISTRATOR:
YEGISHYAN, VREJ
FACILITY TYPE:
740
ADDRESS:
15842 ACRE ST
TELEPHONE:
(818) 726-2805
CITY:
NORTH HILLS
STATE:
CA
ZIP CODE:
91343
CAPACITY:
6
CENSUS:
4
DATE:
03/28/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
01:30 PM
MET WITH:
Anush Badalyan- Licensee
TIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPAs) Leslie Ngo-Castaneda and Liezl De La Cerra conducted an annual required visit and inspection of the facility. LPAs was met with Danil
Stukov
who is the staff and was explained for the reason of the visit. At 3:00 PM Anush Badalayan who is the Licensee met with LPA, explained the reason for the visit.
At 3:24 PM, with the assistance of Licensee, LPAs took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are operational that are located each bedroom, the hallway and kitchen. There are carbon monoxide detectors that functions properly. The fire extinguisher is in the kitchen. The charge date is 3/28/2024. During the visit the facility is at 73 degrees Fahrenheit. The facility is fire cleared for six (06) non-ambulatory residents; 1 bedridden; hospice waiver for 6.
Kitchen:
The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPAs found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked in the drawer. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Cleaning supplies, pesticides or toxic cleaning supplies were stored and locked away in the cabinet under the sink and laundry room.
Bedrooms:
There were four (4) bedrooms designated for residents' use. Bedroom #1 and bedroom #2 are for private used. Bedroom #3 is shared; bedroom #4 is vacant. The bedrooms that are used by residents were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Bedroom #5 is for staff.
Continue to LIC 809-C
SUPERVISOR'S NAME:
Naira Margaryan
TELEPHONE:
(818) 596-4368
LICENSING EVALUATOR NAME:
Leizl De La Cerra
TELEPHONE:
(818) 454-0632
LICENSING EVALUATOR SIGNATURE:
DATE:
03/28/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/28/2024
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
14
Document Has Been Signed on
03/29/2024 11:20 AM
- 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:
BELOVED LIVING
FACILITY NUMBER:
197610356
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/28/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(a)(7)(E)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (7) Procedures that address, but are not limited to, all of the following: (E) Storage and preservation of medications, including the storage of medications that require refrigeration.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 medication was not locked and accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
04/11/2024
Plan of Correction
1
2
3
4
Medication needs to locked at all times.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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 Margaryan
TELEPHONE:
(818) 596-4368
LICENSING EVALUATOR NAME:
Leizl De La Cerra
TELEPHONE:
(818) 454-0632
LICENSING EVALUATOR SIGNATURE:
DATE:
03/28/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/28/2024
LIC809
(FAS) - (06/04)
Page:
2
of
14
Document Has Been Signed on
03/29/2024 11:20 AM
- 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:
BELOVED LIVING
FACILITY NUMBER:
197610356
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/28/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(a)(2)(A)
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products. These activities shall be completed, at a minimum, as follows: (A) Surfaces such as floors, chairs, toilets, sinks, counters and tabletops shall be cleaned and disinfected on a regular basis to ensure they are safe and sanitary. These surfaces shall also be disinfected when these surfaces are contaminated and visibly soiled with blood or body fluids or other potentially infectious material.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 1 out of 1 bathrooms needs to be cleaned, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/11/2024
Plan of Correction
1
2
3
4
Bathroom toilet needs to be cleaned and bathroom skid mat needs to be changed.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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 Margaryan
TELEPHONE:
(818) 596-4368
LICENSING EVALUATOR NAME:
Leizl De La Cerra
TELEPHONE:
(818) 454-0632
LICENSING EVALUATOR SIGNATURE:
DATE:
03/28/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/28/2024
LIC809
(FAS) - (06/04)
Page:
3
of
14
Document Has Been Signed on
03/29/2024 11:20 AM
- 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:
BELOVED LIVING
FACILITY NUMBER:
197610356
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/28/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.17(b)(1)(C)
Licensing
(C) Any person who provides client assistance in dressing, grooming, bathing, or personal hygiene. Any nurse assistant or home health aide meeting the requirements of Section 1338.5 or 1736.6, respectively, who is not employed, retained, or contracted by the licensee, and who has been certified or recertified on or after July 1, 1998, shall be deemed to meet the criminal record clearance requirements of this section. A certified nurse assistant and certified home health aide who will be providing client assistance and who falls under this exemption shall provide one copy of their current certification, prior to providing care, to the residential care facility for the elderly. The facility shall maintain the copy of the certification on file as long as the care is being provided by the certified nurse assistant or certified home health aide at the facility. Nothing in this paragraph restricts the right of the department to exclude a certified nurse assistant or certified home health aide from a licensed residential care facility for the elderly pursuant to Section 1569.58.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 fingerprint clearance which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/11/2024
Plan of Correction
1
2
3
4
Fingerprint clearance needs to be upon hire.
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 Margaryan
TELEPHONE:
(818) 596-4368
LICENSING EVALUATOR NAME:
Leizl De La Cerra
TELEPHONE:
(818) 454-0632
LICENSING EVALUATOR SIGNATURE:
DATE:
03/28/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/28/2024
LIC809
(FAS) - (06/04)
Page:
4
of
14
Document Has Been Signed on
03/29/2024 11:20 AM
- 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:
BELOVED LIVING
FACILITY NUMBER:
197610356
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/28/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(17)(A)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (A) Section 87457, Pre-Admission Appraisal;
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 appraisals which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/11/2024
Plan of Correction
1
2
3
4
Appraisal needs to be done and signed.
Type B
Section Cited
CCR
87506(b)(17)(B)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (B) Section 87459, Functional Capabilities;
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 functional capability which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/11/2024
Plan of Correction
1
2
3
4
Functional capability needs to be done and signed.
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 Margaryan
TELEPHONE:
(818) 596-4368
LICENSING EVALUATOR NAME:
Leizl De La Cerra
TELEPHONE:
(818) 454-0632
LICENSING EVALUATOR SIGNATURE:
DATE:
03/28/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/28/2024
LIC809
(FAS) - (06/04)
Page:
5
of
14
Document Has Been Signed on
03/29/2024 11:20 AM
- 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:
BELOVED LIVING
FACILITY NUMBER:
197610356
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/28/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(17)(C)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (C) Section 87461, Mental Condition;
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 condition which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/11/2024
Plan of Correction
1
2
3
4
Mental condition needs to done and signed.
Type B
Section Cited
CCR
87506(b)(17)(D)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (D) Section 87462, Social Factors;
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 condition which poses/posed a social factors, safety or personal rights risk to persons in care.
POC Due Date:
04/11/2024
Plan of Correction
1
2
3
4
Social factors needs be done and signed.
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 Margaryan
TELEPHONE:
(818) 596-4368
LICENSING EVALUATOR NAME:
Leizl De La Cerra
TELEPHONE:
(818) 454-0632
LICENSING EVALUATOR SIGNATURE:
DATE:
03/28/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/28/2024
LIC809
(FAS) - (06/04)
Page:
6
of
14
Document Has Been Signed on
03/29/2024 11:20 AM
- 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:
BELOVED LIVING
FACILITY NUMBER:
197610356
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/28/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(17)(E)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (E) Section 87463, Reappraisals; and
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 reappraisals which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/11/2024
Plan of Correction
1
2
3
4
Reappraisals needs to be done and signed.
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 pre-appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/11/2024
Plan of Correction
1
2
3
4
Pre-apprisal needs to be signed and dated.
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 Margaryan
TELEPHONE:
(818) 596-4368
LICENSING EVALUATOR NAME:
Leizl De La Cerra
TELEPHONE:
(818) 454-0632
LICENSING EVALUATOR SIGNATURE:
DATE:
03/28/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/28/2024
LIC809
(FAS) - (06/04)
Page:
7
of
14
Document Has Been Signed on
03/29/2024 11:20 AM
- 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:
BELOVED LIVING
FACILITY NUMBER:
197610356
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/28/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(3)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 physician report which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/11/2024
Plan of Correction
1
2
3
4
Physician report needs to be done and signed.
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 retention limitation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/11/2024
Plan of Correction
1
2
3
4
Acceptance and retention limitation needs to be done and signed.
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 Margaryan
TELEPHONE:
(818) 596-4368
LICENSING EVALUATOR NAME:
Leizl De La Cerra
TELEPHONE:
(818) 454-0632
LICENSING EVALUATOR SIGNATURE:
DATE:
03/28/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/28/2024
LIC809
(FAS) - (06/04)
Page:
8
of
14
Document Has Been Signed on
03/29/2024 11:20 AM
- 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:
BELOVED LIVING
FACILITY NUMBER:
197610356
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/28/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 phyical assesment which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/11/2024
Plan of Correction
1
2
3
4
Physicial assesment needs to done with TB test.
Type B
Section Cited
CCR
87458(b)(5)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101(a) or (n), or bedridden as defined in Section 87455(d). The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition or both.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 physical and mental assesment needs to be done which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/11/2024
Plan of Correction
1
2
3
4
Physicial and mental assesment needs to be done and signed.
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 Margaryan
TELEPHONE:
(818) 596-4368
LICENSING EVALUATOR NAME:
Leizl De La Cerra
TELEPHONE:
(818) 454-0632
LICENSING EVALUATOR SIGNATURE:
DATE:
03/28/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/28/2024
LIC809
(FAS) - (06/04)
Page:
9
of
14
Document Has Been Signed on
03/29/2024 11:20 AM
- 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:
BELOVED LIVING
FACILITY NUMBER:
197610356
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/28/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 reappraisals which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/11/2024
Plan of Correction
1
2
3
4
Reappraisals needs to be done and signed.
Type B
Section Cited
HSC
1569.695(e)(3)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (3) A resident medication list for residents with centrally stored medications.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 CSMDR which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/11/2024
Plan of Correction
1
2
3
4
CSMDR needs to be done for every resident. Facility should not just rely on Hospice med lists.
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 Margaryan
TELEPHONE:
(818) 596-4368
LICENSING EVALUATOR NAME:
Leizl De La Cerra
TELEPHONE:
(818) 454-0632
LICENSING EVALUATOR SIGNATURE:
DATE:
03/28/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/28/2024
LIC809
(FAS) - (06/04)
Page:
10
of
14
Document Has Been Signed on
03/29/2024 11:20 AM
- 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:
BELOVED LIVING
FACILITY NUMBER:
197610356
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/28/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 condition for bed rails which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/11/2024
Plan of Correction
1
2
3
4
Bedrails needs to be prescription or doctor orders.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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 Margaryan
TELEPHONE:
(818) 596-4368
LICENSING EVALUATOR NAME:
Leizl De La Cerra
TELEPHONE:
(818) 454-0632
LICENSING EVALUATOR SIGNATURE:
DATE:
03/28/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/28/2024
LIC809
(FAS) - (06/04)
Page:
11
of
14
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:
BELOVED LIVING
FACILITY NUMBER:
197610356
VISIT DATE:
03/28/2024
NARRATIVE
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Bathrooms:
There are two (2) bathroom designated for residents' and staff use. The bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 116 degrees Fahrenheit for bathroom #1 located inside bedroom #2. Bathroom #1 needs to have the toilet cleaned and changed the non-skid mat. Deficiency will be cited on LIC 809-D. Bathroom #2 is across bedroom #4. Hot water temperature was measured at 117.2 degrees Fahrenheit. There was enough clean linen available in the cabinets in the hallway.
Common Areas:
LPAs toured all common areas of the facility. These included the living room and dining area for residents. The common areas were properly furnished. Residents dining table fits enough for six (6). LPAs observed common areas to be very clean and tidy. Fire place is close, block-off, and non-operational. LPAs observed the floors to be in very good condition. No obstructions and or tripping hazards throughout the facility. Furniture in common area was observed to be in good repair. There are no issues with Fire Clearance.
Infection control
: Facility mitigation plan to make sure licensee was following current infection control recommendations. LPA obtain a copy and reviewed the infection control plan during this visit.
Surrounding Grounds
: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The facility does not have a swimming pool or body of water. The garage detached and is used for storage.
Laundry service:
Laundry is beside the kitchen. There is enough linen available to change weekly or more if need. Cleaning supplies are being stored in a locked cabinet in the kitchen under the sink and laundry room.
Staff Files
: LPAs also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Office space is beside the dining table. Records were checked for expired or missing certificates and clearances: LPAs conducted a file review of staff for criminal record clearances and current First Aid. The administrator file was reviewed for current first aid, fingerprint clearance, and HIV/AIDS and TB training. Facility has missing fingerprint clearance for one (1) out of four (4) staff review. Civil penalty will be issued.
Continue to LIC 809-C
SUPERVISOR'S NAME:
Naira Margaryan
TELEPHONE:
(818) 596-4368
LICENSING EVALUATOR NAME:
Leizl De La Cerra
TELEPHONE:
(818) 454-0632
LICENSING EVALUATOR SIGNATURE:
DATE:
03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/28/2024
LIC809
(FAS) - (06/04)
Page:
12
of
14
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:
BELOVED LIVING
FACILITY NUMBER:
197610356
VISIT DATE:
03/28/2024
NARRATIVE
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Medications
are in a centrally stored and locked place, including over-the-counter medicines; medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged. Medication was not lock when LPA arrived. Deficiency will be cited on LIC 809- D. Proper medication dispensing instruction are followed and checked for contamination. First-aid has all proper items and is current.
Resident records
were reviewed for requirements and legibility: LPA reviewed client’s files for current records only for some residents. Two (2) out of four (4) residents are missing physicians report, appraisals, functional capability, TB test, and diagnoses. Deficiencies will be issued on LIC 809-D. Planned activities are offered.
Facility is within CA code of Regulations Title 22 or Health and Safety Code. Deficiencies were found, this will on LIC 809-D, exit interview conducted, copy of report has been issued and discussed.
SUPERVISOR'S NAME:
Naira Margaryan
TELEPHONE:
(818) 596-4368
LICENSING EVALUATOR NAME:
Leizl De La Cerra
TELEPHONE:
(818) 454-0632
LICENSING EVALUATOR SIGNATURE:
DATE:
03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/28/2024
LIC809
(FAS) - (06/04)
Page:
13
of
14