198603543-10-3-2023-31-AS-BPEA-CW9Q4F-20231003115016

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603543
Report Date: 10/03/2023
Date Signed: 10/03/2023 11:51:18 AM

Document Has Been Signed on 10/03/2023 11:51 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME:	GLENOAKS SENIOR GARDEN		FACILITY NUMBER:	198603543
ADMINISTRATOR:	TEKEIAN, DIANA		FACILITY TYPE:	740
ADDRESS:	834 E GLENOAKS BLVD		TELEPHONE:	(818) 726-4871
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91207
CAPACITY:	5	CENSUS: 0	DATE:	10/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:28 AM
MET WITH:	Ana Papazyan-Marketing Manager and Marijan Tekeian - Family Member		TIME COMPLETED:	12:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Bennette Pena conducted the required annual inspection. LPA was allowed entry by Marijan Tekeian, Family member and explained the purpose of today's visit. Administrator/Licensee Diana Tekeian is unavailable and out of town. At, 10:10am, Ana Papazyan, Marketing Manager arrived and assisted LPA with the inspection. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has submitted a COVID-19 Mitigation Plan. Infection Control Plan was not reviewed as Marketing Manager cannot locate the file. Common area surfaces are being cleaned and disinfected on a regular basis. Bathrooms have soap and paper towels. Staff will adhere to infection control requirements.

Operational Requirements: A current Plan of Operation was not reviewed, as Marketing Manager cannot locate the file. A fire clearance is in place. Liability Insurance policy in the amount of $1,000,000.00 each occurrence and #3,000,000.00 in the total annual aggregate is valid and will expire on 6/18/2024. No fire drill has been conducted yet.

Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood that is licensed to serve 5 ambulatory residents ages 60 and over, of which (1) may be bedridden and (1) may be non ambulatory in bedroom #3. There is also a hospice waiver for (2). There is zero (0) resident in the facility during the visit. Home consists of three (3) bedrooms, (2) bathrooms, living room, dining room, family area, kitchen, backyard, and a detached garage. The fireplace in the living room is adequately screened. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Currently, there is a construction going on in the front yard and the back yard. According to the Marketing Manager, the on-going construction is to fix plumbing issues and landscaping. Smoke and carbon monoxide detectors are operational. The facility has (2) fire extinguishers in the facility that are fully charged, one mounted on the wall in the living room and the other one in the kitchen. Cleaning supplies and toxic substances are stored in a locked cabinet. At 9:45am, hot water temperature readings measured 111.7 deg F in bathroom #1 and 108.1 deg F in bathroom #2 which are within the required 105-120 degrees Fahrenheit.

***CONTINUED ON LIC 809-C***

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: 323-981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

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

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: GLENOAKS SENIOR GARDEN	FACILITY NUMBER: 198603543
	VISIT DATE: 10/03/2023

NARRATIVE

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Staffing: There are zero (0) staff associated to the facility and additional staff will be hired according to the Marketing Manager. There will be (3) total staff members including the Administrator who will provide care and supervision to the residents. Additional staff will be hires as needed. LPA notified the Marketing Manager that staff to be employed should be over the age of 18 and have criminal background clearance, fingerprint cleared, have the required training and associated to the facility. TAs issued.

Personnel Records-Training: Administrator certificate is valid and will expire on 12/19/2023. No staff files were reviewed as there were no staff employed during the visit. LPA informed the Marketing Manager that future staff to be employed who will provide care and supervision to the residents should have the required training and associated to the facility. TA was issued.

Resident Records-Incident Reports: No resident files were reviewed during the visit.

Resident Rights-Information: Resident personal rights are posted.

Planned Activities: There is sufficient space to accommodate indoor activities. However, due to the on-going construction at the facility, outdoor activity area is inaccessible and there is no covered space and furniture available for future residents.

Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. The food is properly stored in the refrigerator (clean, labeled and well maintained). Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Incident Medical and Dental: A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored in locked cabinet near the dining area which are inaccessible to residents. However, the non aspirin tablets expired on 8/2023.

Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, operation of manual assist devices.

Pursuant to Title 22, deficiencies were cited on the attached 809D and Technical Assistance were issued. An exit interview was conducted and a copy of the report was provided to the Ana Papazyan-Marketing Manager.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: 323-981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

LIC809 (FAS) - (06/04)

Page: 2 of 10

Document Has Been Signed on 10/03/2023 11:51 AM - 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
Lookup Error,
, CA

FACILITY NAME: GLENOAKS SENIOR GARDEN	FACILITY NUMBER: 198603543
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87208(a)

Plan of Operation

(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, record review, the licensee did not comply with the section cited above in that the Marketing Manager cannot locate the plan of operation which shall be maintained and filed in the facility which poses/posed a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 10/09/2023
	Plan of Correction
1 2 3 4	Administrator/Licensee shall ensure that plan of operation is maintained and filed in the facility and will submit a copy of the plan to CCL/LPA by POC due date.

Type B

Section Cited

CCR

87208(a)(12)

Plan of Operation

(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (12) The Infection Control Plan pursuant to Section 87470. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, record review, the licensee did not comply with the section cited above in that the Marketing Manager cannot locate the Infection Control Plan which poses/posed a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 10/09/2023
	Plan of Correction
1 2 3 4	Administrator/Licensee will submit the current Infection Control Plan to CCL/LPA 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: David Sicairos	TELEPHONE: (323)981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: 323-981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

LIC809 (FAS) - (06/04)

Page: 3 of 10

Document Has Been Signed on 10/03/2023 11:51 AM - 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
Lookup Error,
, CA

FACILITY NAME: GLENOAKS SENIOR GARDEN	FACILITY NUMBER: 198603543
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(a)(8)(A)

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in which the non aspirin tabletsin the first aid kit has expired on 08/2023 which poses/posed a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 10/09/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator to ensure that first aid kit is complete and up to date. Administrator will submit receipt/photos of new first aid kit to CCL/LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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: David Sicairos	TELEPHONE: (323)981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: 323-981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

LIC809 (FAS) - (06/04)

Page: 10 of 10