191805246-9-28-2022-31-AS-LQLY-CJPUH9-20220928153534

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191805246
Report Date: 09/28/2022
Date Signed: 09/28/2022 03:35:49 PM

Document Has Been Signed on 09/28/2022 03:35 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BEL AIR GUEST HOME		FACILITY NUMBER:	191805246
ADMINISTRATOR:	SAMUEL, GALINA		FACILITY TYPE:	735
ADDRESS:	1440 NO. STANLEY AVENUE		TELEPHONE:	(323) 876-3370
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90046
CAPACITY:	64	CENSUS: 57	DATE:	09/28/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:31 AM
MET WITH:	Galina Samuel		TIME COMPLETED:	02:50 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	Licensing Program Analyst (LPA) LaQueena Lacy arrived at the facility at approximately 11:24am on 09/28/2022 to conduct a Comprehensive One (1) year Required Infection Control visit. LPA meet with Galina Samuel and explained the purpose of the visit. The facility has an approved mitigation plan on file. A tour of the physical plant was conducted at 11:38am and the following was observed: The facility has a fire clearance for fifty-eight (58) ambulatory residents and six (06) non- ambulatory. The facility has one main entrance being used, there are required Covid-19 prevention signage (hand washing, and physical distancing) posted. The PPE screening station is located in the office equipped with sufficient PPE readily accessible, thermometer, sign in sheet, hand sanitizer, gloves and mask, at the time of visit. The facility is a two (02) story building. LPAs observed multiple fire extinguishers located throughout the facility in the kitchen, first and second floors located on the wall to all have a service tag dated 12/06/2022. The facility recently had a Los Angeles Fire Department Fire Protection Equipment Performance Report conducted on 04/26/2022 for the fire alarm with passing results. Kitchen: At 11:43am LPA and staff #1 (S1) observed the kitchen to be clean and free from obstruction. Appliances observed to be in good repair and functional. The clients are served meals through a window in the kitchen area. LPA observed (02) refrigerators and a (02) deep freezers stocked with a variety of perishable and non-perishable foods to be properly labeled and stored. Bedrooms: At 11:59am LPA and S1 observed eleven (11) random bedrooms with the bathrooms located inside of the bedrooms on the first and second floor to be appropriately furnished with sufficient lighting. LPA observed appropriate bed linen and comforters on all beds. Continued on LIC809C

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BEL AIR GUEST HOME	FACILITY NUMBER: 191805246
	VISIT DATE: 09/28/2022

NARRATIVE

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LPA observed S1 and S2 pull back all linens and mattress coverings to inspect all mattresses for any pest. During the inspection LPA and staff did not observe any pest in the bedrooms or on any mattresses or coverings. All bedrooms observed to be clean and clear from obstruction.
Bathroom: At 11:59am LPA and S1 observed eleven (11) random bathrooms located inside of the bedrooms on the first and second floor. Bathrooms are stocked and equipped with soap and hands towel are not shared each client has their own towels for use.
Medications: LPA observed the medication cabinet at 12:47pm located in the second office space that is inaccessible to clients in care. LPA observed the medication to be in a bin and each clients medication is rubber band together. Medication is distributed in the front office or the dining room. The facility has a first aid kit located in the office all staff have keys to the office.
Living, dining room and common areas: At 12:54pm LPA observed these areas to be appropriately furnished with tables and chairs and adequate lighting to be neat and clean and free from obstruction. The outside area and surrounding grounds were observed to be neat and clear from debris or obstruction. Clients enjoy lounging under the cover carport that is equipped with table and chairs for seating.

Due to time constraints, LPA was not able to complete the comprehensive annual and will return at a later date to complete the inspection.

Exit interview conducted and copy of report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022

LIC809 (FAS) - (06/04)

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