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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610495
Report Date: 08/06/2024
Date Signed: 08/06/2024 01:56:34 PM

Document Has Been Signed on 08/06/2024 01:56 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:ROSSMOYNE HILLSFACILITY NUMBER:
197610495
ADMINISTRATOR/
DIRECTOR:		AVETISYAN, ARMINEFACILITY TYPE:
740
ADDRESS:1227 CAMPBELL STREETTELEPHONE:
(747) 324-6116
CITY:GLENDALESTATE: CAZIP CODE:
91207
CAPACITY: 6CENSUS: 4DATE:
08/06/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Albert KhachatryanTIME VISIT/
INSPECTION COMPLETED:
02:05 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
At 9:30 a.m. on 08/06/24, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with staff and disclosed the reason for the visit. LPA and staff toured the facility inside and out.

During the course of investigating complaint #31-AS-20240730093716, multiple deficiencies were observed in the facility which were unrelated to the complaint.

At approximately 9:40 a.m., LPA observed three (03) staff members working in the facility. At 11:45 a.m. LPA reviewed the staff associated to the facility. At approximately 1:45 p.m. LPA called the administrator to confirm the names, start dates, and associations of staff working in the facility. The administrator confirmed that two (02) out of three (03) staff did not have criminal background clearances or associations to the facility. This deficiency is cited on the corresponding LIC 809-D page. In addition, due to Staff #2 (S2) and Staff #3 (S3) working in the facility for longer than one (01) month until today, a civil penalty is issued in the amount of $1,000 ($100 per day, per staff, up to five (05) days) on the corresponding LCI 421BG page.

During the 1:45 p.m. phone interview with administrator, it was revealed that an incident report was not submitted to Community Care Licensing for the hospitalization of Resident #1 (R1) on 07/26/24. This violation of reporting requirements is cited on the corresponding LIC 809-D page.

Exit interview conducted. Appeal rights discussed. Copy of report provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024
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 2
Document Has Been Signed on 08/06/2024 01:56 PM - It Cannot Be Edited


Created By: Nicholas Reed On 08/06/2024 at 12:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROSSMOYNE HILLS
FACILITY NUMBER: 197610495

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/07/2024
Section Cited
CCR
87355(e)

1
2
3
4
5
6
7
87355 Criminal Record Clearance
(e) All individuals ... shall prior to working... in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The licensee has agreed to associate all staff to the facility prior to their returning to work by the POC due date.
8
9
10
11
12
13
14
Based on interview, record review, and observation, the licensee did not comply with the section cited above in () out of () staff not being associated to the facility which poses an immediate health, safety, or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
08/16/2024
Section Cited
CCR87211(a)(1)(D)

1
2
3
4
5
6
7
87211 Reporting Requirements (a) Each licensee shall furnish... (1) A written repor... within seven days of ... (D) Any incident which threatens the welfare, safety or health of any resident
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
The administrator has agreed to submit an incident report for the event and a written statement confirming the section has been reviewed.
8
9
10
11
12
13
14
Based on record review and interview, the licensee did not comply with the section cited above in one (01) hospitalozation of R1 which poses a potential health, safety or personal rights risk to persons 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 Margaryan
LICENSING EVALUATOR NAME:Nicholas Reed
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2