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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610522
Report Date: 05/23/2024
Date Signed: 05/23/2024 02:33:14 PM


Document Has Been Signed on 05/23/2024 02:33 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:VELORI SENIOR LIVINGFACILITY NUMBER:
197610522
ADMINISTRATOR:DANIELYAN, RENAFACILITY TYPE:
740
ADDRESS:20414 KESWICK STREETTELEPHONE:
(818) 934-7783
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY:6CENSUS: 6DATE:
05/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Irina Raskopina & Ivan GorskikhTIME COMPLETED:
10:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted a case management, in conjunction with complaint control # 31-AS-20240517163642. During the initial visit, LPA identified (2) staff that were not finger print cleared, nor was associated with the facility. Civil penalties will be assess during the visit. This is an immediate health and safety risk to residents in care.

Also during the investigation, and reviewing resident records and staff files, LPA observed both staff did not have a personnel file at the facility and Licensing required documents were not available to be reviewed. The following items were missing:
  • 1st Aid/CPR certificate
  • Fingerprint clearance and association to the facility
  • LIC501 – Personnel application
  • LIC503 – Health Screening
  • LIC508 – Criminal Record Statement
  • LIC9052 – Employee rights
  • TB Test
  • LIC198 – Child Abuse Index form


  • LPA informed Licensee that all documents must be submitted by the POC date.

  • Exit interview, appeal rights, copy of report provided.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024
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 05/23/2024 02:33 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: VELORI SENIOR LIVING
FACILITY NUMBER: 197610522

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/24/2024
Section Cited
CCR
87355(b)

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Criminal Record Clearance: (b) Prior to the Department issuing a license, the applicant, administrator and any adults other than a client, residing in the facility shall have a criminal record clearance or exemption. This requirement was not met, evidenced by, during today's complaint visit, LPA
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Licensee has AGREED to submit to LPA by 5pm on 05/24/2024, completed applications to start the fingerprint clearance process. On 05/28/2024, both staff will get fingerprint cleared and submit proof to LPA via email.
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reviewed the personnel summary for (2) staff that were at the facilty and they did not have a fingerprint clearance. This is an immediate health and safety risk to residents in care.
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Type B
06/10/2024
Section Cited
CCR87412(a)

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Personnel Records: (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement was not met, evidenced by, based on file review during today's visit
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Licensee has AGREED to compile all Licensing required documents for staff and create personnel files for the (2) staff that were missing documents during today's visit. All documents must be submitted by POC date.
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LPA observed (2) staff with no personnel record or file at the facility. All Licensing required documents were missing. This is an 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: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2