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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610567
Report Date: 07/23/2024
Date Signed: 07/23/2024 02:57:54 PM


Document Has Been Signed on 07/23/2024 02:57 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:SAINT MARIAM SENIOR CAREFACILITY NUMBER:
197610567
ADMINISTRATOR:HAYRAPETYAN,VIKTORYAFACILITY TYPE:
740
ADDRESS:18228 ACRE STREETTELEPHONE:
(213) 476-2354
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY:6CENSUS: 6DATE:
07/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:09 AM
MET WITH: Viktorya HayrapetyanTIME COMPLETED:
03:15 PM
NARRATIVE
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On 07/23/24, Licensing Program Analyst (LPA) Gina Saucedo, conducted unannounced, subsequent visit to this facility in conjunction with a complaint control #31-AS-20240711170640. LPA met with the Administrator, Viktorya Hayrapetyan and explained the reason for the visit.

During the physical tour, LPA Saucedo witnessed an empty bed with a staff's belongings on it and asked the resident who was sleeping on that bed. The resident stated that it was a staff that had slept there the night before. LPA Saucedo took a picture of the staff's belongings.

During the physical tour, LPA conducted a review of records and no incident report was sent to Community Care Licensing Departmen-(CCLD) for the multiple times that resident #1 (R1) had fallen in the facility. In addition, a death report was not sent to CCLD regarding a previous hospice resident that had passed away.

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 to the Administrator.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina SaucedoTELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
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 07/23/2024 02:57 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: SAINT MARIAM SENIOR CARE
FACILITY NUMBER: 197610567

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/24/2024
Section Cited
CCR
87211(a)(1)(A)

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87211 (a)(1)(A)Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports... including, but not limited to, the following:(1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below... This requirement is not met as evidenced by:
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An Unusual Report is to be sent to Community Care Licensing Department within seven (7) days regarding a death report and resident injuries while in care.
POC 07/24/24
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Based on the LPA observation and interviews the licensee/administrator did not ensure multiple reports to be submitted to CCLD from the above facility involving multiple incidents which poses an Immediate Health, Safety or Personal Rights risks to persons in care.
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Type A
07/24/2024
Section Cited
CCR87307(a)

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87307(a) Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. This requirement is not met as evidenced by:
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The licensee/admnistrator shall remove the staff bed immediately whom is sharing a room with one (1) of the residents. The licensee/administrator shall send a picture of the bed removal.
POC 07/24/24
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Based on the LPA observation and interviews the licensee/administrator did not provide comfortable living accommocations and privacy to the staff/resident which poses an Immediate Health, Safety or Personal Rights risks to persons 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: Gina SaucedoTELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
LIC809 (FAS) - (06/04)
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