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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603493
Report Date: 02/01/2024
Date Signed: 02/01/2024 12:55:30 PM


Document Has Been Signed on 02/01/2024 12:55 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:MOON LIGHT BOARDING CARE INCFACILITY NUMBER:
198603493
ADMINISTRATOR:SAKO MANVELYANFACILITY TYPE:
740
ADDRESS:120 N SIERRA BONITA AVETELEPHONE:
(818) 661-7333
CITY:PASADENASTATE: CAZIP CODE:
91106
CAPACITY:6CENSUS: 5DATE:
02/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Adrine Adamian - CaregiverTIME COMPLETED:
01:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with and explained the reason for the visit.

The facility is licensed to served (6) non-ambulatory residents over the age of 60, of which (1) may be bedridden, with a hospice waiver for (4). The facility is a single home located in a residential neighborhood and consist of a living/dining room area, a kitchen, (4) resident bedrooms, (4) resident bathrooms, (1) staff/visitor's bathroom, a front porch, a backyard, and a detached garage.

LPA toured the facility with an observed the following:
Facility is in good repair indoor and outdoor. Passageways, ramps, exits are free of obstruction and debris. Living/dining room has sufficient sitting area, and fire place is covered. A linen closet was observed. Kitchen area is clean. Sharps, cleaning supplies, and medication were observed locked. Sufficient food supplies were observed for at least 2 days of perishables and 7 days of non-perishables. Laundry room is located in the basement and additional grooming supplies were observed. Each room (4) was observed with the required furniture, and sufficient lighting. Resident #2(R2) in room #2 was observed with bed rails and a request was not on file. Each resident bathroom (4) was observed in working condition, with grab bars and skid mats and water temperature was tested between 113.5-126.1 degrees F. which is not within the required 105-120 degrees F. All required posting was observed throughout the facility. Carbon Monoxide/ Smoke detectors were observed, tested, and in working condition. Fire extinguishers were observed and last checked on 1/17/24. Backyard has a sitting area and front porch provides a cover sitting area.
LPA reviewed medication and files for 5 residents. Resident #5(R5) was missing a pre-placement assessment. Files for 5 staff were reviewed. Administrator certificate #6066207740 exp. date: 9/8/25. Infection control plan and Emergency Disaster plan were reviewed and were updated within the last year.
Deficiencies are noted on LIC 809D per Title 22 Regulations.
Exit interview was conducted with Sako Manvelyan and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2024
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 4


Document Has Been Signed on 02/01/2024 12:55 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: MOON LIGHT BOARDING CARE INC
FACILITY NUMBER: 198603493

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in water temperature in bathroom #1 tested at 126.1 degrees F., #2 tested at 113.5 degrees F., #3 tested at 122.5 degrees F., and #4 tested at 124.7 degrees F., which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/02/2024
Plan of Correction
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Administrator will adjust water temperature and will submit in writing certifying will ensure water temperature is within the 105-120 degrees at all times by POC due date 2/2/24. A daily log will be keep for the next 7 days of temperature in each bathroom and will be submitted to the department on 2/8/24.
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: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 02/01/2024 12:55 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: MOON LIGHT BOARDING CARE INC
FACILITY NUMBER: 198603493

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation andn record review, the licensee did not comply with the section cited above in resident #2 (R2) has bed rails in bed and a physician's request is not on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/08/2024
Plan of Correction
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Administrator will submit a copy of physician request for half bed rails to the department by POC due date 2/8/24.
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: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4