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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610441
Report Date: 06/12/2024
Date Signed: 06/12/2024 02:50:35 PM


Document Has Been Signed on 06/12/2024 02:50 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:A NEW LIFE BOARD AND CAREFACILITY NUMBER:
197610441
ADMINISTRATOR:KARAPETYAN, GURGENFACILITY TYPE:
740
ADDRESS:19435 STRATHERN STTELEPHONE:
(747) 237-2337
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:6CENSUS: 5DATE:
06/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Gurgen Karapetyan, Adminidtrator TIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angela Panushkina and Licensing Program Manager (LPM) Nichelle Gillyard, conducted unannounced visit to this facility in conjunction with a complaint control #31-AS-20240606110421. LPA and LPM met with the Administrator and explained the reason for the visit.

During the visit, LPA and LPM conducted a physical plan tour and the following was observed:
  • Patio furniture was broken
  • Living room exit door was blocked with arm chairs and floor light. Moreover, bedroom #4 exit door was blocked with an oxygen concentrator.
  • Facility did not have a Oxygen in Use sign posted
  • Bedroom # 2 door did not require to have a screen, however, the facility implemented a magnetic screen to be able to leave the door open and prevent flies from coming in. LPA and LPM observed the screen was ripped and in poor repair.


Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC 809D.

Exit interview conducted, appeal rights and copy of report signed and delivered.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024
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 06/12/2024 02:50 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: A NEW LIFE BOARD AND CARE
FACILITY NUMBER: 197610441

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/19/2024
Section Cited
CCR
87303(a)

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Maintenance and Operation: (a) 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 as evidenced by:
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Administrator agreed to purchase a new patio furniture and submit a prove of receipt to LPA. Moreover, a magnetic screen in room #4 will be replaced and proof of picture will be submitted.
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Based on LPA and LPM's observation, licensee did not comply with the section cited above by having a broken patio table in a backyard. This poses a potential health and safety risk to residents in care.
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Type B
06/19/2024
Section Cited
CCR87307(d)(6)

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Personal Accommodations and Services: (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
This requirement is not met as evidenced by:
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During today's visit, the Administrator and staff cleared the passageways from the obstruction in the living room and bedroom
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Based on LPA and LPM's observation, licensee did not comply with the section cited above by blocking the exit door in a living room and room #4. 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 GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 06/12/2024 02:50 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: A NEW LIFE BOARD AND CARE
FACILITY NUMBER: 197610441

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/19/2024
Section Cited
CCR
87618(b)(3)(B)

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Oxygen Administration - Gas and Liquid: b) the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements: (B) "No Smoking-Oxygen in Use" signs shall be posted in the appropriate areas.
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Administrator shall post an appropriate sign and submit proof of picture to LPA
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Based on LPA and LPM's observation, licensee did not comply with the section cited above by not posting Oxygen in Use sign. 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 GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024
LIC809 (FAS) - (06/04)
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