Leo's Assisted Living II

Type of visit: Required - 1 Year

At 9:15 AM Licensing Program Analyst (LPA), Huma Rahimi, conducted an unannounced annual inspection at the facility mentioned above. LPA met with staff, Aroksya Arzumanyan and the Administrator Khatchik Danielian, was contacted via phone. LPA explained the reason for the visit. Physical tour was conducted with the staff and LPA observed the following: The facility is a single storey building and has three (3) bedrooms for residents use, one (1) office, and two (2) bathrooms. Fire cleared for six (6) non-ambulatory residents, one (1) of which maybe bedridden on Room #1. Hospice waiver for six (6) residents. Kitchen: At 9:20 AM LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. Knives and sharps are observed to be locked in the kitchen drawer and inaccessible to residents. Toxins and cleaning solutions were locked under the sink. Medications: LPA observed that the medication are kept in the filing cabinet in the dinning area and was observed to be locked and inaccessible to residents in care. Review of medication did not reveal any discrepancy during today's visit. Bedrooms: LPA observed total of three (3) bedrooms designated for residents use. All bedrooms contained a nightstand, storage, and bed with adequate bedding. All furnishings were clean and in good condition. Facility has an awake staff at the facility. Continue on LIC809-C Bathrooms: LPA observed two (2) bathrooms of which one is designated for staff and one for residents. The bathroom for the staff was observed locked and inaccessible to residents in care. The bathroom for residents appeared to be clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bar and resident’s bathroom had non-skid mat. LPA observed appropriate hand washing signs posted in each bathroom. At 9:30 AM, hot water temperature measured at 113.4°F. Common Areas: The facility maintains a comfortable temperature at 77°F. The living room and dining area appeared clean and were properly furnished. The living room has a television, comfortable furniture. No obstructions and or tripping hazards throughout the facility. The fireplace was covered with a locked screen. The laundry room is located in the hallway. Laundry detergent, cleaning solutions and other toxins are observed to be locked inside the laundry room. A new and charged fire extinguisher hung near the kitchen purchased on 01/29/2025. Smoke detectors/carbon monoxide. The facility has a dual-function smoke and carbon monoxide detectors and at 9:35 AM, they were tested and observed to be operational. Garage: There is no garage at the facility only drive ways. The Backyard/Outside: had a covered shaded area for residents with outdoor furniture. There is no body of water at the facility. The facility has only one emergency exit. The emergency exit was unlocked with an inward facing latch. Emergency exit paths were free from debris. Between 9:45 AM to 10:45 AM, LPA reviewed records of three (3) residents and two (2) staff. Residents and staff files were observed to be completed/updated. Administrative: LPA collected Certificate of Liability Insurance, and LIC500. No deficiency issued. Exit interview conducted. Copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Sep 16, 2025

Type of visit: Office

Licensing Regional Manager (RM) Angela Whittaker, Licensing Program Manager (LPM) Nichelle Gillyard, and Licensing Program Analyst (LPA) Huma Rahimi met with the Administrator Khatchik Danielian to conduct an office meeting held at the Woodland Hills South Adult and Senior Care Regional Office. The purpose of the office meeting was to discuss the property ownership and control of the above listed address. Current Census: 3 RM, LPM, and LPA were informed that the property ownership still belongs to the same owner Meruzhan A Sayadyan; however, the lease agreement between the owner and Anna Gharibyan, the Licensee expired on 02/28/2025. The Administrator informed RM, LPM, and LPA that the application which was submitted to the Community Care Licensing (CCL) Centralized Application Bureau (CAB) under Oasis II Assisted Living was initially denied on 12/23/2023. On 08/11/2025, the Administrator was contacted by CAB to re-submit the original application for Oasis II Assisted Living as the twelve (12) month wait period was over ; however, the Administrator voluntarily withdrew the application on 08/13/2025. Furthermore, the facility is now in the process of changing facility's ownership from Leo's II Assisted Living to Caring Hearts Assisted Living with a new a application and new Licensee, Aram Yeghiazaryan. An application is being submitted and received by CAB on 08/15/2025. In the meantime, the Administrator was informed to submit a letter of intent from Leo's II Assisted Living to CCLD and to three (3) out of three (3) residents in care. Moreover, the Administrator was informed to submit a new lease agreement between the Licensee Anna Gharibyan of Leo's II Assisted Living and the property owner to the department while the application for Caring Hearts Assisted Living is in process. Exit interview conducted. Copy of this report signed and provided.the state’s words, verbatim · CDSS document, Aug 26, 2025

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Huma Rahimi and Angela Panushkina conducted an unannounced Case Management visit to this facility to issue a Notice of Operation in Violation of Law (NOVL). Upon arrival, LPAs met with the staff, Lilya Gevorgyan, who granted access to the facility. The staff contacted Designee, Liana Agaronyan, and LPAs explained the reason for the visit. On 08/26/2020, Community Care Licensing Division (CCLD) issued a license to Leo’s Assisted Living II, Ana Garibyan (President) for the above location. On 12/19/2022, the current Operator/Administrator Khatchik Danielian submitted a new application for the above location under Oasis II Assisted Living (197610389) which was denied on 12/22/2023, per H&S code 1569.15(a)(2)- Failure to provide evidence of reputable and responsible character. Based on Business search of the facility through California Secretary of State, the Licensee Leo’s Assisted Living II lost control of the property and is now operating unlicensed under Khatchik Danielian (Operator). Moreover, RO reviewed facility file, and it was revealed that the lease between the landlord Meruzhan Sayadyan and Licensee Anna Garibyan expired on 02/28/2025, and no lease back was submitted to the Department. Furthermore, on 06/19/2025, a case management visit was conducted and interviews with staff revealed that Khatchik Denielian is the owner of the business as well as provides salary to staff. During the case management and today’s visit LPAs were informed that there are three (3) residents of which one (1) is non-ambulatory and two (2) are ambulatory. Currently, none of the residents receive Hospice and or Home Health. Continue on LIC 809C LPAs were also informed that the Operator/staff store and manage medications, provide assistance with incontinent care, bathing, dressing, grooming, arrange medical appointment, etc. Lastly, during today’s visit, the Designee confirmed that no new application was submitted to Community Care Licensing (CCL). A Notice of Operation in Violation of Law (NOVL) is issued. The Operator was advised that a retroactive civil penalty of $100 per day per tenant shall be assessed from the original date of the NOVL 08/07/2025 for the operation of an unlicensed facility. If the Operator has not ceased operation within 15 calendar days of the issuance of this notice, a $200 per resident per day will be assessed beginning on the 16th day until the operation ceases. LPAs spoke with the Operator and was informed that a new application is submitted to CCL. Deficiency cited on LIC809-D. Exit interview conducted, appeal rights explained and copy of this report was signed and issued.the state’s words, verbatim · CDSS document, Aug 7, 2025

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.10 · Plan of correction due date: Aug 22, 2025

1569.10 RCFE; license or permit; necessity No person, firm, partnership, association, or corporation within the state.....without a current valid license or current valid special permit... This requirement is not met as evidenced by: Based on interviews conducted, LPAs were informed that R1, R2, R3, were receiving elements of care and supervision, which posed an immediate health and safety risk or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 7, 2025

Plan of correction: Operator will submit an application to CCL by the POC due date of 8/22/2025.

Type of visit: Case Management - Other

At 1:00 p.m. on 06/19/25, Licensing Program Manager (LPM) Naira Margaryan and Licensing Program Analysts (LPAs) Nicholas Reed and Huma Rahimi conducted an unannounced case management visit. LPA met with staff and disclosed the reason for the visit. Today’s case management visit was conducted to ensure the health and safety of facility residents and the facility’s compliance to Title 22 Regulations. LPM and LPAs interviewed staff and residents between 1:10 p.m. and 2:00 p.m. today, conducted a record review of pertinent records, including but not limited to an admission agreement, medical assessment, care plan, and staff and client rosters at 1:25 p.m., and toured the facility inside and out at 1:30 p.m. Interview with Staff #1 (S1) at approximately 1:15 p.m. revealed today was their first day working in the facility. File review at 1:20 p.m. today revealed S1 was not associated to the facility. Telephonic interview with the administrator at approximately 1:35 p.m. confirmed today was S1’s first day working and they were not associated to the facility. A deficiency is issued for S1 not being associated to the facility on the corresponding LIC 809-D page. Record review of staff files revealed the most recent trainings were conducted on 05/15/22. Additionally, the facility did not maintain a staff file for S1. Interview with the administrator revealed staff trainings have been conducted annually, but the certificates are not available for audit today. A deficiency is assessed for not maintaining necessary files at the facility and making them available for audit. Record review of Resident #1’s (R1) file revealed their most recent medical assessment was incomplete and did not contain a primary diagnosis. A deficiency is issued for an incomplete medical assessment. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Jun 19, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(c)(1) · Plan of correction due date: Jun 20, 2025

87355 Criminal Record Clearance (c) A licensee... may... transfer of a criminal record clearance... by providing... (1) A signed Criminal Background Clearance Transfer Request, LIC 9182 This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above by not submitting the LIC 9182 for Staff #1 (S1) which poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 19, 2025

Plan of correction: Licensee to submit S1's LIC 9182 to the Woodland Hills Regional Office by tomorrow, 06/20/25 in order to associate S1 to the facility.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(g) · Plan of correction due date: Jul 4, 2025

87412 Personnel Records (g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above by not producing recent staff trainings for audit which poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 19, 2025

Plan of correction: Licensee to email proof of staff training certificates to the Department and make copies available within the facilty by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87458(c)(1) · Plan of correction due date: Jul 4, 2025

87458 Medical Assessment (c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses. Based on interview and record review, the licensee did not comply with the section cited above by not ensuring the diagnoses of Resident #1 (R1) were listed in their medical assessment which poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 19, 2025

Plan of correction: Licensee to obtain an updated physican report and submit updates by the POC due date.

Type of visit: POC

Licensing Program Analyst (LPA) Huma Rahimi conducted a Plan of Correction (POC) visit subsequent to citation issued during the Complaint 31-AS-20240904120011 conducted on 09/30/2024. LPA met with the staff Marine Arzumanyan. The staff contacted Khatchik Danielian, the Administrator and Administrator designated the caregiver Araksi Arzumanyan who arrived at the facility shortly after. LPA explained the reason for the visit. 87411(d)(3): Personnel Requirements - General POC: Administrator/Licensee agrees to put in writing their plan for hiring or ensuring English Speaking staff are always on shift and submit the plan by the POC date. Additionally, Administrator shall submit an updated LIC500 to reflect all staff. During the previous visit conducted on 09/30/2024, LPA observed two staff member being scheduled; however, both staff did not communicate in English to provide care to residents. During today's visit LPA observed the same two staff available and no new staff present who can care for residents. The staff who communicates in English arrived at the facility after the staff contacted the Administrator. Based on today's observation the POC is not corrected. Deficiency and civil penalty issued. Appeal rights explained, Exit interview conducted. Copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Oct 24, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(3) · Plan of correction due date: Oct 28, 2024

87411-Personnel Requirements - General-(d):experience shall provide knowledge of and skill in the following, as appropriate for the job....effective job performance.. Skill and knowledge required to...supervision,. This requirement is not met as evidenced by: Based on LPA interview with staff, the administrator did not have staff available to communicate with residents and emergency personnel effectively which poses a potential risk to the residents in care.the state’s words, verbatim · CDSS document, Oct 24, 2024

Plan of correction: Administrator/Licensee agrees to put in writing their plan for hiring or ensuring English Speaking staff are always on shift and submit the plan by the POC date. Additionally, Administrator shall submit an updated LIC500 to reflect all staff.

Type of visit: Required - 1 Year

At 9:50 AM Licensing Program Analyst (LPA), Huma Rahimi, conducted an unannounced annual inspection at the facility mentioned above. LPA met with staff, Mariam Arzumanyan and later Administrator, Khatchik Danielian, arrived and LPA explained the reason for the visit. Physical tour was conducted with the Administrator and LPA observed the following: The facility is a single storey building and has three (3) bedrooms for residents use, one (1) office, and two (2) bathrooms. Fire cleared for six (6) non-ambulatory residents, one (1) of which maybe bedridden on Room #1. Hospice waiver for six (6) residents. Kitchen: At 11:15 AM LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. Knives and sharps are observed to be locked in the kitchen drawer and inaccessible to residents. Toxins and cleaning solutions were locked under the sink. Medications: LPA observed that the medication are kept in the filing cabinet inside the office and was observed to be locked and inaccessible to residents in care. Review of medication did not reveal any discrepancy during today's visit. Bedrooms: LPA observed total of three (3) bedrooms designated for residents use. All bedrooms contained a nightstand, storage, and bed with adequate bedding. All furnishings were clean and in good condition. Facility has an awake staff at the facility. LPA observed half bed rails for resident # (3) in bedroom # (1), without doctor's order. Administrator informed LPA that half bed rails are requested by the family. Continue on LIC809-C Bathrooms: LPA observed two (2) bathrooms of which one is designated for staff and one for residents. Both appeared to be clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bar and resident’s bathroom had non-skid mat. LPA observed appropriate hand washing signs posted in each bathroom. At 11:32 AM, hot water temperature measured at 113.4°F. Common Areas: The facility maintains a comfortable temperature at 78°F. The living room and dining area appeared clean and were properly furnished. The living room has a television, comfortable furniture. No obstructions and or tripping hazards throughout the facility. The fireplace was covered with a locked screen. The laundry room is located in the hallway. Laundry detergent, cleaning solutions and other toxins are observed to be locked inside the laundry room. A new and charged fire extinguisher hung near the kitchen purchased on 06/13/2024. Smoke detectors/carbon monoxide. The facility has a dual-function smoke and carbon monoxide detectors and at 11:36 AM, they were tested and observed to be operational. Garage: There is no garage at the facility only drive ways. The Backyard/Outside: had a covered shaded area for residents with outdoor furniture. There is no body of water at the facility. The facility has only one emergency exit. The emergency exit was unlocked with an inward facing latch. Emergency exit paths were free from debris. Between 12:00 PM to 1:15 PM, LPA reviewed records of four (4) residents and two (2) staff. There was no current medical assessment for resident # 1 and resident # 3. Resident last medical assessment was done on 03/22/2022. Resident # 3 did not have any medical assessment and TB test results on file. Residents and staff records appeared to be complete and updated. Administrative: LPA collected Certificate of Liability Insurance, and LIC500. Deficiencies cited on LIC 809D. Exit interview conducted. Appeal rights explained and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Aug 13, 2024

Type of visit: Required - 1 Year

At 9:00 AM Licensing Program Analyst (LPA), Huma Rahimi, conducted an unannounced annual inspection at the facility mentioned above. LPA met with staff, Mariam Arzumanyan and later Administrator, Khatchik Danielian, arrived and LPA explained the reason for the visit. Physical tour was conducted with the Administrator and LPA observed the following: The facility is a single storey building and has three (3) bedrooms for residents use, one (1) office, and two (2) bathrooms. Fire cleared for six (6) non-ambulatory residents, one (1) of which maybe bedridden on Room #1. Hospice waiver for six (6) residents. Kitchen: At approximately, 9:30 AM LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. Knives and sharps are observed to be locked in the kitchen drawer and inaccessible to residents. Toxins and cleaning solutions were locked under the sink. Medications: LPA observed that the medication are kept in the filing cabinet inside the office and was observed to be locked and inaccessible to residents in care, however, review of R1's random medication revealed that the facility was supposed to start Lisinopril (Blood Pressure Medication) a new bottle on 03/03/2024. During today's visit LPA counted R1's medication and it was discovered that there was a discrepancy and six (6) extra pills were in the bottle. LPA asked the Administrator and the staff for explaining and both staff could not provide any answers. LPA also observed Centrally Stored Medication (LIC 622) records and did not observe staff filling the box when the medication start date. A deficiency will be cited. There was a complete first aid kit located on top of the medication cabinet in the office. Bedrooms: LPA observed total of three (3) bedrooms designated for residents use. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Facility has an awake staff. Continue on LIC809-C Bathrooms: LPA observed two (2) bathrooms of which one is designated for staff and one for residents. Both appeared to be clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bar and resident’s bathroom had non-skid mat. LPA observed appropriate hand washing signs posted in each bathroom. At 9:47 AM, hot water temperature measured at 111.4°F. Common Areas: The facility maintains a comfortable temperature at 68°F. The living room and dining area appeared clean and were properly furnished. The living room has a television, comfortable furniture. No obstructions and or tripping hazards throughout the facility. The fireplace was covered with a locked screen. The laundry room is located in the bedroom hallway. Laundry detergent, cleaning solutions and other toxins are observed to be locked inside the laundry room. A new and charged fire extinguisher hung near the kitchen purchased on 03/15/2024. Smoke detectors/carbon monoxide. The facility has a dual-function smoke and carbon monoxide detectors and at 9:55 AM, they were tested and observed to be operational. Garage: There is no garage at the facility only drive ways. The Backyard/Outside: had a covered shaded area for residents with outdoor furniture. There is no body of water at the facility. The facility has only one emergency exit. The emergency exit was unlocked with an inward facing latch. Emergency exit paths were free from debris. Between 10:00 AM to 11:45 AM, LPA reviewed records of three (3) residents and three (3) staff. Residents and staff records appeared to be complete and updated. Administrative: LPA collected Certificate of Liability Insurance, and LIC500. A deficiency cited on LIC 809D. Exit interview conducted. Appeal rights explained and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Mar 15, 2024

Type of visit: Case Management - Other

At 10:15 a.m. on 03/05/2024, Licensing Program Analysts (LPAs) Nicholas Reed and Raymond Comer conducted an unannounced case management visit. LPAs met with staff and later the Administrator and disclosed the reason for the visit. The purpose of today’s case management visit is to explain that a new application at the facility address was denied on 12/22/2023 and no new application may be submitted for a 12-month period. The administrator confirmed at 10:20 a.m. that the facility would continue normal operations under the current license. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Mar 5, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPA) Mariana Agban conducted a follow up unannounced visit to this facility in conjunction with a complaint control #31-AS-20231009085600. LPA met with the Administrator and explained the reason for the visit. After further investigation LPA reviewed and obtained staff records. Records revealed that staff#2 (S2) doesn't have fingerprint and background clearance. Staff#2 (S2) started employment at this facility in June of 2022 and Staff#3 (S3) does have fingerprint and background clearance, but is not associated to this facility. According to S3 they started employment at this facility about two years ago. There were no transfer request forms in the personnel file. The Licensee/Administrator did not request a transfer with the department. This was previously cited on 07-27-2023. Deficiencies and civil penalty issued. Appeal rights given. Exit interview conducted.the state’s words, verbatim · CDSS document, Oct 19, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Oct 20, 2023

All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... in a licensed facility: (2)Request a transfer of a criminal record clearance as specified in Section 87355(c)... This requirement is not met as evidence by:Based on interviews and review of the personnel file one staff(S3) is not associated to the facility. This poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Oct 19, 2023

Plan of correction: Admnistrator agreed to transfer Staff 3(S3) and assosiate them to the facility.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355(e)(1) · Plan of correction due date: Oct 20, 2023

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: (1) Obtain a California clearance or a criminal record exemption as required by the Department This requirement is not met as evidence by:Based on interviews and review of the personnel file one staff(S2) is not background cleared to the facility. This poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Oct 19, 2023

Plan of correction: Administrator will remove S2 immedatley and will not allow them to return until they obtain background clearance and assosition to the facility. Administrator will sumbit all documents to LPA when complete.

Allegation investigated: Staff forced resident to assign licensee as resident's substitute payee. Staff does not ensure bathroom needs are being met. Staff does not allow resident to communicate with resident's family.

At 10:00am, Licensing Program Analysts (LPAs) Mariana Agban, and Huma Rahimi conducted an unannounced initial complaint visit at this facility to investigate the above allegations. LPAs granted access to the facility by staff. Administrator arrived shortly after and LPAs explained the reason for the visit. During course of the investigation, interviews and record review were made. At 10:10am, LPAs requested resident and staff roster. At 10:20am, LPAs requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, etc., relevant to the investigation. LPAs conducted file review and observed missing Physcian's report, incomplete Admission Agreement for R1. At approximately 10:30am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 10:40am – 12:10pm, LPA interviewed the Administrator, two (2) staff and four (4) residents and the Administrator. Unsubstantiated Allegation: Staff forced resident to assign licensee as resident's substitute payee. It was alleged that R1 was forced to assign the administrator as resident's substitute payee. Administrator denied the allegation. Administrator stated that R1 was responsible for their own finances. Administrator stated that for the 2 weeks R1 was in the facility R1 didn't provide any form of payment to the Administrator. Administrator contacted R1's family to become the POA of R1 to provide any sort of payment. Interview with 2 staff and 3 residents revealed that they didn't witness any resident being forced to assign licensee as resident's substitute payee. Allegation: Staff does not ensure bathroom needs are being met. It was alleged that R1's bathroom needs are not being met. Administrator denied the allegation. Interviews with 3 residents revealed that staff frequently assist residents with their bathroom needs. Residents stated that they have a call on button for immediate assistance as well as staff do rotation checks for each resident. Allegation: Staff does not allow resident to communicate with resident's family. It was alleged that R1 is being isolated and was prevented from contacting their family. Administrator denied the allegation. Administrator stated that R1 was homeless and didn't have family initially. Per Administrator, R1 didn't talk to their family for years and didn't know their contact information. Administrator stated R1 and R1's sister had many phone calls in regards the sister becoming the POA. Interview with 3 residents revealed that they are allowed to contact their families at any time. Based on inspection, observation and interviews there is no sufficient evidence to support the allegation. Therefore, all allegations are Unsubstantiated at this time. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Oct 18, 2023 · control 31-AS-20231009085600

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Mariana Agban and Huma Rahimi conducted unannounced visit to this facility in conjunction with a complaint control #31-AS-20231009085600. LPAs met with the Administrator and explained the reason for the visit. During the visit, LPAs observed two (2) incidents for 2 residents that were not submitted to the Community Care Licensing Department (CCLD) in a timely manner. Moreover, Administrator informed LPAs that R1 was hospitalized on 10/03/2023. LPAs reviewed all incident reports on a system and did not observe an Incident Report regarding R1. In addition, the Administrator admitted that no incident was submitted to the Regional Office (RO). Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPAs informed the Administrator that all staff members are mandated reporters and they are all responsible for reporting. LPAs informed the Administrator to submit the following two (2) incidents that occurred on: 10/03/2023 (one incident) 10/06/2023 (one incident) In addition, review of R1's record revealed that the facility file is incomplete/missing documents. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC 809D. Exit interview conducted, appeal rights and copy of report signed and delivered.the state’s words, verbatim · CDSS document, Oct 18, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)A,B,D · Plan of correction due date: Oct 25, 2023

Requirements (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)... This requirement is not met as evidenced by: Based on interviews and record reviews, conducted by LPA, the licensee did not comply with the section cited above by failing to notify CCLD regarding the five (5) incidents that occured on 10/3/23 and 10/6/23 which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 18, 2023

Plan of correction: Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. Copies of 2 incidents, shall be submitted to LPA by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(a) · Plan of correction due date: Oct 25, 2023

87506 Resident Records: (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above. Resident records were incomplete and or missing documents, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 18, 2023

Plan of correction: Administrator will sumbit a written explanation on how to manage residents files for future addmissions.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Mariana Agban and Huma Rahimi conducted unannounced visit to this facility in conjunction with a complaint control #31-AS-20231009085600. LPAs met with the Administrator and explained the reason for the visit. During the visit it was observed that staff #2 (S2) and staff #3 (S3) were working in the facility without being associated with this facility. Record review revealed S2 and S3 do have fingerprint and background clearance, but is not associated to this facility. Employee records revealed S2 started employment at this facility in June of 2022. In addition, Staff #3 (S3) started employment at this facility about two years. Interviews with residents and staff corroborate S2 and S3 have worked in the facility and provided assistance to residents. Team requested and reviewed personnel files. There were no transfer request forms in the personnel file. The Licensee/Administrator did not request a transfer with the department. This was previously cited on 07-23-2023. A civil penalty will be issued. Due to time constrains LPA was unable to complete citations. The Administrator was informed that additional visit will follow to render the citations. Copy of this report provided, appeal form given. Exit interview conducted.the state’s words, verbatim · CDSS document, Oct 18, 2023