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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603605
Report Date: 07/24/2024
Date Signed: 07/24/2024 11:48:17 AM


Document Has Been Signed on 07/24/2024 11:48 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:ARARAT GARDENSFACILITY NUMBER:
198603605
ADMINISTRATOR:KESHISHYAN, VARSENIKFACILITY TYPE:
741
ADDRESS:1230 EAST WINDSOR ROADTELEPHONE:
(818) 244-7219
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:175CENSUS: 78DATE:
07/24/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:32 AM
MET WITH:Edemida Vasquez- LVNTIME COMPLETED:
12:37 PM
NARRATIVE
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This case management visit is conducted by the Licensing Program Analyst (LPA) Leslie Ngo-Castaneda in conjunction with complaint investigation visit to address the issues unrelated to the complaint.

On 6.19.2024 while LPA was conducting complaint investigation, LPA conducted a random inspection of one (1) pendant one (1) emergency pull cords in the bathroom, and one (1) emergency pull cords in the bedroom. During the inspection one (1) pendant call was received by the facility and a caregiver responded to the call in eight (8) minutes and four (4) minutes consecutively. However, at 11:30 AM, LPA tested the residents' pendant and emergency cord in room #122 and waited until 11:50 AM. No staff showed up to reset the call buttons.

Therefore, based on the observation and interviews of three (3) out of six (6) staff admitted it was concluded that the facility has insufficient staffing.

Under Title 22 Regulations, the following citation is issued and recorded on LIC809D.

No immediate health and safety hazard is noted at the time of this visit. Exit interview was conducted. Appeal rights discussed and a copy of report was issued.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-CastanedaTELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024
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 07/24/2024 11:48 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: ARARAT GARDENS
FACILITY NUMBER: 198603605

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/25/2024
Section Cited
CCR
87411(a)

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Personnel Requirements-General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.

This requirement was not met by evidence of:
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Cleared during visit. Two (2) new staff was hired and started today 7.24.2024 (Wednesday) and 7.26.2024 (Friday).
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Based on observation, record review and interviews conducted, facility staff failed to meet the needs of resident (R1) when call button was press.This poses an immediate health and safety risk to residents 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: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-CastanedaTELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024
LIC809 (FAS) - (06/04)
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