191222081-6-19-2023-31-AS-JGTN-CSXUCU-20230619152830

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191222081
Report Date: 06/19/2023
Date Signed: 06/19/2023 03:31:47 PM

Document Has Been Signed on 06/19/2023 03:31 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ARARAT HOME OF LOS ANGELES		FACILITY NUMBER:	191222081
ADMINISTRATOR:	RITA NORAVIAN		FACILITY TYPE:	741
ADDRESS:	15105 MISSION HILLS RD.		TELEPHONE:	(818) 365-3000
CITY:	MISSION HILLS	STATE: CA	ZIP CODE:	91345
CAPACITY:	186	CENSUS: 80	DATE:	06/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:52 AM
MET WITH:	Rita Noravian - Administrator		TIME COMPLETED:	03:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	An unannounced Required One (1) Year visit to this facility is conducted today by Licensing Program Analyst (LPA) Gary Tan. LPA met with the Administrator Rita Noravian and explained the reason for the visit. Facility is currently licensed for a capacity of 186 ambulatory, 118 of which may be non-ambulatory and hospice waiver for one (1) resident. There is currently no resident receiving hospice care services. There is only one entrance being utilized at the facility, there are required poster posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility has an approved mitigation and infection control plan on file. LPA conducted physical plant tour of the facility with the Administrator at 9:20 AM. Facility currently has forty (40) residents on the Assisted Living Waiver (ALW) program. The facility has three stories. Residents' bedrooms on the first, second, and third floors were inspected. Common areas, including the activity rooms, meeting rooms, dining rooms and a gym, all appeared clean and were properly furnished. The kitchen appeared clean and the appliances and fixtures functional. Refrigerated and frozen foods were stored at proper temperatures. There was a sufficient amount of perishable and non-perishable food at the facility and properly stored. Residents do not have access to the kitchen; dangerous items are stored inaccessible to residents. The facility menu appears to meet the daily dietary needs for residents. There were no pesticides or poisons observed near any food areas. Entry/exits were free of obstruction. The outdoor area was clean and free of hazards. The patios and balconies have proper furnishings. The medications were locked in the medication room, properly labeled and stored. Medication documentation and implementation appeared to be complete. Personal accommodations in resident bedrooms and bathrooms were observed for safety, privacy, and comfort. Random resident rooms are inspected and observed with all required furnishings and grab bars and nonskid surfaces in the bathrooms. Hot water temperature in random resident bathrooms on all floors were checked, hot water temperature range from 105.1°F to 112.8°F and within the required range. (continued on LIC 809-C)

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ARARAT HOME OF LOS ANGELES	FACILITY NUMBER: 191222081
	VISIT DATE: 06/19/2023

NARRATIVE

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(continued from LIC 809)

LPA observed fire extinguishers and pull stations throughout the facility hallways on all three floors, fire extinguishers were full and current. First aid kits are located in the medication room on the second floor and staff room on the first floor.

The facility's smoke alarms are hard wired with electric generator set as back up and tests are done in house on a monthly basis, last test was conducted on 06/16/23. Facility emergency disaster plan was reviewed. Facility disaster drills are conducted monthly and was last conducted on 05/08/2023. A fire protection equipment performance certification was conducted on 09/24/21 with expiration date of 11/30/23. Nurse call system were tested and observed to be operable.

In addition to the physical plant inspection, residents and staff records were reviewed.

LPA reviewed files of randomly selected residents. Files included signed admission agreements, current appraisals, current medical assessments, physician orders for medications and centrally stored medication logs. Medications appear to be given as prescribed. Staff present files were also reviewed and appeared to be complete and updated.

According to the California Code of Regulations, Title 22, Division 6, Chapter 8, there is no health and safety hazard observed during today's inspection.

Exit interview conducted and copy of report issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

LIC809 (FAS) - (06/04)

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