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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191805183
Report Date: 08/17/2024
Date Signed: 08/17/2024 12:44:09 PM


Document Has Been Signed on 08/17/2024 12:44 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:ST. JOHN OF KRONSTADT HOMEFACILITY NUMBER:
191805183
ADMINISTRATOR:LIANA VERTELKINAFACILITY TYPE:
740
ADDRESS:655 NO. SERRANOTELEPHONE:
(323) 466-6467
CITY:LOS ANGELESSTATE: CAZIP CODE:
90004
CAPACITY:21CENSUS: 14DATE:
08/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:19 AM
MET WITH:Hrpsime Avalyan - STaffTIME COMPLETED:
01:00 PM
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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 Hrpsime Avalyan and explained the reason for the visit.

The facility is licensed to serve 21 ambulatory only, residents over the age of 60. The facility is located in a residential area and consist of a one story building with 19 resident rooms/with bathrooms, a recreation room, kitchen, dining area, laundry room, medication room, 3 storage rooms, 3 community showers, office, staff restroom and visitor restroom and outside shaded patio.

LPA toured the facility with Vita Kravchenko - Staff and observed the following:
Facility is clean and in good repair inside and outside. Kitchen was observed and sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were stored. Sharps are stored in the kitchen. Cleaning supplies are stored in storage areas. All common areas have sufficient seating furniture and in good repair. LPA randomly choose 5 resident rooms and observed each has the required furniture, sufficient bedding, and lighting. Water temperature was tested in the bathroom's between 113.7-114.8 degrees F., which is within the required 105-120 degrees F. Common showers were observed and each has the required grab bars and skid mat/strips. The building has a fire sprinkler system throughout. Fire extinguishers were observed and last checked on 9/20/23. No large bodies of water were observed. Passageways were clear of obstructions.

LPA reviewed medication and files for 5 residents, and 5 staff files and interviewed 3 staff and 3 residents.

LPA reviewed Infection Control Plan and Emergency Disaster Plan.

No deficiencies were noted during this visit.

Exit interview was conducted with Liana Vertelkina and a copy of this report was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2024
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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