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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320039
Report Date: 07/17/2023
Date Signed: 07/17/2023 04:48:29 PM

Document Has Been Signed on 07/17/2023 04:48 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:BEL AIR HOMEFACILITY NUMBER:
198320039
ADMINISTRATOR:LILLIAN GHODSIANFACILITY TYPE:
772
ADDRESS:11240 CHALON ROADTELEPHONE:
(310) 709-7355
CITY:LOS ANGELESSTATE: CAZIP CODE:
90049
CAPACITY: 6CENSUS: 5DATE:
07/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:38 AM
MET WITH:Dr. Sharouz Ghodsian, Program DirectorTIME COMPLETED:
04:59 PM
NARRATIVE
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On 07/17/2023 Licensing Program Analyst (LPA) David España conducted an unannounced required Annual visit. Upon arrival at the facility, LPA España conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19. LPA met with staff, Dr. Sharouz Ghodsian, Program Director and toured the inside and outside grounds of the facility.

The facility 4-bedroom, 4-bath, single story with full basement, social rehab facility that is licensed for 6 ambulatory adults. During the tour, LPA observed the facility’s infection control practices and sufficient food supplies were observed. LPA observed required posting throughout the facility. Bathroom in basement was checked, sufficient liquid soap and paper towels were observed. Water in basement bathroom tested within range. Toilets and water faucets worked properly. The water temperature measured at restroom was between 105F and 120 degrees Fahrenheit. A comfortable temperature was maintained throughout the facility.

LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food, all not dated. Knives and other sharps were observed accessible to clients in care. First Aid kit was observed in the facility. Fire extinguishers were observed throughout the facility, with all being current. Outside grounds were toured, LPA España observed a pool on site with the gate secured. Walkways around the facility were clear of hazards. Common areas were clean and clear of hazards; doorways were free of obstructions.

The following deficiencies were cited:

Type B:

Client Records - Incident Reports - Type B: 81069(f)(1) - LPA España and Dr. Sharouz Ghodsian, Program Director observed that Residents 1, 2, 3, 4, and 5 are missing LIC613C and TB.

Disaster Preparedness - Type B: 1565(a) - LPA España and Dr. Sharouz Ghodsian, Program Director observed no plan approved at facility at the time of visit.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2023
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 07/17/2023 04:48 PM - It Cannot Be Edited


Created By: David Espana On 07/17/2023 at 04:09 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BEL AIR HOME
FACILITY NUMBER: 198320039

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81069(f)(1)
Client Medical Assessments
(f) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/ infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. LPA España and Dr. Sharouz Ghodsian, Program Director observed that Residents 1, 2, 3, 4, and 5 are missing LIC613C and TB, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/17/2023
Plan of Correction
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The administrator/licensee agreed to address missing records for residents ensuring resident safety. The licensee shall submit plan of correction to ensure cited deficiency do no reoccur at the facility. The administrator of record shall update the resident's/staff's in-services plans within 30 days.
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. LPA España and Dr. Sharouz Ghodsian, Program Director observed no emergency plan approved at facility at the time of visit, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/17/2023
Plan of Correction
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The administrator/licensee agreed to address 9 page emergency plan for residents ensuring resident safety. The licensee shall submit plan of correction to ensure cited deficiency do no reoccur at the facility. The administrator of record shall update the resident's/staff's in-services plans within 30 days.
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:Ulysses Coronel
LICENSING EVALUATOR NAME:David Espana
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/17/2023 04:48 PM - It Cannot Be Edited


Created By: David Espana On 07/17/2023 at 04:19 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BEL AIR HOME
FACILITY NUMBER: 198320039

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81066(e)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. LPA España and Dr. Sharouz Ghodsian, Program Director observed that staff 1, 2, 3, 4, 5 and 6 are missing LIC501, LIC503, LIC508, TB, LIC9052, TB, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2023
Plan of Correction
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The administrator/licensee agreed to address all missing LICs forms and TB for staff for residents ensuring resident safety. The licensee shall submit plan of correction to ensure cited deficiency do no reoccur at the facility. The administrator of record shall update the resident's/staff's in-services plans within 30 days.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Ulysses Coronel
LICENSING EVALUATOR NAME:David Espana
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2023


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BEL AIR HOME
FACILITY NUMBER: 198320039
VISIT DATE: 07/17/2023
NARRATIVE
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81066 Personnel Records - LPA España and Dr. Sharouz Ghodsian, Program Director observed that staff 1, 2, 3, 4, 5 and 6 are missing LIC501, LIC503, LIC508, TB, LIC9052, TB, which poses/posed a potential health, safety or personal rights risk to persons in care.

An exit interview was conducted with Dr. Sharouz Ghodsian, and a copy of this report was provided to Licensee/Administrator.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023
LIC809 (FAS) - (06/04)
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