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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603309
Report Date: 06/16/2021
Date Signed: 06/16/2021 05:56:09 PM

Document Has Been Signed on 06/16/2021 05:56 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:WOODLYN LIVING CARE, LLCFACILITY NUMBER:
198603309
ADMINISTRATOR:GALADJIAN, BAGDASARFACILITY TYPE:
740
ADDRESS:2515 E WOODLYN RDTELEPHONE:
(626) 398-9555
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6CENSUS: 0DATE:
06/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Anjela Agadjanova, administratorTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Administrator, Anjela Agadjanova who assisted with the visit. The facility is licensed to serve residents who are age range 60 years old and over. The facility has a capacity of six (6) non-ambulatory residents which one (1) may be bedridden. Approved Hospice Waiver is six (6) residents. Administrator has no staff or resident since the facility is licensed. The resident census is 0 and staff census is 0.

During the visit, the infection control domain tool was used, a tour of the facility was conducted, and food supply was reviewed and medications were reviewed.

The facility is a two-story house with a kitchen, living, a dining room, 4 resident bedrooms, 4 resident bathrooms, front and back yards, laundry room in the backyard, and garage. The facility has a central a/c and heat. All smoke detectors are combined with carbon monoxide detectors and functioning properly. Beds have required linen and the bedrooms are equipped with required furniture. There is sufficient closet and drawer space in the resident bedrooms. Bathrooms are clean and operational with grab bars and non-skid surface mats/strips in place. Hot water temperature was in a range from 115.4 to 118.5 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies are observed. Emergency lighting was observed. Activity supplies are available. The facility has a working telephone. Sufficient supply of perishable and nonperishable foods. The fire extinguishers are fully charged. The first aid kit is fully stocked with manual. There is shaded areas with ample seating. Fire/ Emergency drill was not yet conducted since no staff and resident but will conduct it quarterly when staff and residents are in.

Deficiencies were observed and cited per California Code of Regulations, Title 22, Division 6. See LIC809-D pages for deficiencies.

(see page LIC 809 C-)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2021
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 10
Document Has Been Signed on 06/16/2021 05:56 PM - It Cannot Be Edited


Created By: Bonnie Tao On 06/16/2021 at 02:01 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WOODLYN LIVING CARE, LLC
FACILITY NUMBER: 198603309

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)


This requirement is not met as evidenced by: Individuals, Baghdasar G. and Svetalan N who are residing at the faciltiy did not have a transfer of a criminal record clearance.
Deficient Practice Statement
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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(2) Request a transfer of a criminal record clearance as specified in Section 87355(c)
Based on interview, the licensee did not comply with the section cited above in which poses/posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/17/2021
Plan of Correction
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Adminstrator will have the individuals to move out from the facility by COB 6/17/21 and send a statement to confirm it.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2021


LIC809 (FAS) - (06/04)
Page: 8 of 10
Document Has Been Signed on 06/16/2021 05:56 PM - It Cannot Be Edited


Created By: Bonnie Tao On 06/16/2021 at 02:02 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WOODLYN LIVING CARE, LLC
FACILITY NUMBER: 198603309

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)


This requirement is not met as evidenced by: Trash, used auto parts and debris are observed in the backyard.
Deficient Practice Statement
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Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times.
Based on interview, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2021
Plan of Correction
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Administrator will remove the trash and clean up the backyard. Administrator will take pictures and send them to Licensing upon by POC due date.
Type B
Section Cited
CCR
87307(a)(2)(A)


This requirement is not met as evidenced by: Resident room #3 was stored with activity supplies, boxes, used funiture and other obstacles. Passageway is blocked.
Deficient Practice Statement
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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. The following provisions shall apply: ...
(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements:
(A) Bedrooms shall be large enough to allow for easy passage between and comfortable usage of beds and other required items of furniture specified below, and any resident assistant devices such as wheelchairs or walkers.
Based on interview, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2021
Plan of Correction
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Administrator will remove the trash and clean up resident room #3. Administrator will take pictures and send them to Licensing upon by POC due date.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2021


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 06/16/2021 05:56 PM - It Cannot Be Edited


Created By: Bonnie Tao On 06/16/2021 at 03:53 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WOODLYN LIVING CARE, LLC
FACILITY NUMBER: 198603309

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)


This requirement is not met as evidenced by: Two Individuals Baghdasar G and Svetalan N, who are not residents nor staff, are living in resident room #1.
Deficient Practice Statement
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87307 Personal Accommodations and Services
(a) Living accommodations and grounds shall be related to the facility's function.
Based on interview, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2021
Plan of Correction
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Administrator will have the individuals move out by COB due date. Administrator provides a statement to confirm it after they move out.
Type B
Section Cited
CCR
87506(a)


This requirement is not met as evidenced by: Administrator did not maintain Resident file, folder and cabinets.
Deficient Practice Statement
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(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
Based on observation and interview, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
Based on interview, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2021
Plan of Correction
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Administrator will mainitain resident files and a lock cabinet to keep the files. Administrator will take pictures and send them to Licensing upon by POC due date.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2021


LIC809 (FAS) - (06/04)
Page: 2 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: WOODLYN LIVING CARE, LLC
FACILITY NUMBER: 198603309
VISIT DATE: 06/16/2021
NARRATIVE
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An exit interview was conducted. Plans of Corrections were reviewed and developed with the administrator. A copy of this report and Appeal Rights were discussed and provided to Administrator, whose signature on this form confirm receipt of these documents.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021
LIC809 (FAS) - (06/04)
Page: 10 of 10
Document Has Been Signed on 06/16/2021 05:56 PM - It Cannot Be Edited


Created By: Bonnie Tao On 06/16/2021 at 05:23 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WOODLYN LIVING CARE, LLC
FACILITY NUMBER: 198603309

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(2)
Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (a)(2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2021
Plan of Correction
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Administrator will work on LIC 808 mitigation plan and be sure facililty will have a plan to report occurrences to icensing agency and to the local health officer when appropriate. Administrator will submit LIC 808 to Licensing upon POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2021


LIC809 (FAS) - (06/04)
Page: 9 of 10
Document Has Been Signed on 06/16/2021 05:56 PM - It Cannot Be Edited


Created By: Bonnie Tao On 06/16/2021 at 05:23 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WOODLYN LIVING CARE, LLC
FACILITY NUMBER: 198603309

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2021
Plan of Correction
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Administrator will work on LIC 808 mitigation plan and be sure facililty will have a plan to monitor staff and resident on Covid concern. Administrator will submit LIC 808 to Licensing upon POC due date.

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:Fernando Fierros
LICENSING EVALUATOR NAME:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2021


LIC809 (FAS) - (06/04)
Page: 7 of 10
Document Has Been Signed on 06/16/2021 05:56 PM - It Cannot Be Edited


Created By: Bonnie Tao On 06/16/2021 at 05:23 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WOODLYN LIVING CARE, LLC
FACILITY NUMBER: 198603309

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Administrator will work on LIC 808 mitigation plan and be sure facililty will have a plan to report occurrences to icensing agency and to the local health officer when appropriate. Administrator will submit LIC 808 to Licensing upon POC due date.
POC Due Date: 06/29/2021
Plan of Correction
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3
4
Administrator will work on LIC 808 mitigation plan and be sure facililty will have a plan to monitor staff and resident on Covid concern. Administrator will submit LIC 808 to Licensing upon POC due date.
Type B
Section Cited
CCR
87303(a)
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:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2021
Plan of Correction
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2
3
4
Administrator will work on LIC 808 mitigation plan and be sure facililty will have a plan to monitor staff and resident on Covid concern. Administrator will submit LIC 808 to Licensing upon POC due date.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2021


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 06/16/2021 05:56 PM - It Cannot Be Edited


Created By: Bonnie Tao On 06/16/2021 at 05:23 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WOODLYN LIVING CARE, LLC
FACILITY NUMBER: 198603309

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)
Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2021
Plan of Correction
1
2
3
4
Administrator will work on LIC 808 mitigation plan and be sure facililty will have a plan to monitor staff and resident on Covid concern. Administrator will submit LIC 808 to Licensing upon POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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2
3
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:Fernando Fierros
LICENSING EVALUATOR NAME:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2021


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 06/16/2021 05:56 PM - It Cannot Be Edited


Created By: Bonnie Tao On 06/16/2021 at 05:23 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WOODLYN LIVING CARE, LLC
FACILITY NUMBER: 198603309

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(a)
Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2021
Plan of Correction
1
2
3
4
Administrator will work on LIC 808 mitigation plan and be sure facililty will have a plan to monitor staff and resident on Covid concern. Administrator will submit LIC 808 to Licensing upon POC due date.

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:Fernando Fierros
LICENSING EVALUATOR NAME:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2021


LIC809 (FAS) - (06/04)
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