195850089-2-3-2022-29-AS-SURA-CBAQ2S-20220203104735

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850089
Report Date: 02/02/2022
Date Signed: 02/03/2022 10:48:06 AM

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	MARY ELLEN HOMES		FACILITY NUMBER:	195850089
ADMINISTRATOR:	KHACHATRYAN, GOHAR		FACILITY TYPE:	740
ADDRESS:	7752 MARY ELLEN AVENUE		TELEPHONE:	(818) 279-1415
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY:	6	CENSUS: 3	DATE:	02/02/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Gohar Khachatryan		TIME COMPLETED:	03:30 PM

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On 02/02/2022, Licensing Program Analyst (LPA) Sandra Urena, arrived at the facility unannounced to conduct a required annual inspection. LPA Urena arrived at the facility at 1:30 p.m., and was greeted by the staff. The administrator was not present at facility and the staff call the administrator to announce the LPA’s visit. The administrator stated that they would arrive at the facility in 30 minutes. This annual inspection had a specific emphasis on infection control practices and procedures. The purpose of the inspection was discussed with the administrator Gohar Khachatryan.

Infection Control: Upon entry, the facility has a sign in book and sanitizing gel. Infection Control signage was visible at entrance. Temperature was checked and recorded.

At 2:00 p.m., LPA Urena and administrator conducted a tour of the inside and outside the facility to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Common Areas: At 2:00 p.m., the common seating area, and dining room furniture were observed to be in good condition. Fire extinguisher was observed to be serviced within the last year. Walls, and floors were in clean condition

Kitchen: At 2:05 p.m., LPA Urena and administrator observed the kitchen/dining area. Knives are stored in a locked cabinet drawer. Kitchen appliances were in operable condition. The facility has enough supply of perishable and non-perishable food. Freezer and refrigerator are stocked with a variety of foods. Emergency food supply is adequate for six residents and two staff.

Continues on LIC 809C...

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MARY ELLEN HOMES	FACILITY NUMBER: 195850089
	VISIT DATE: 02/02/2022

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Bedrooms: At 2:10 p.m., LPA Urena observed the residents’ bedrooms. Bedrooms were furnished appropriately with appropriate furnishings and sufficient lighting. Linens are clean and in good condition.

Bathrooms: At 2:15 p.m., LPA Urena observed the residents’ restrooms. Restrooms were clean, shower area was in clean condition with grab bars and a non-skid mat available. Paper towels were available for drying hands. Handwashing signs were displayed, and sufficient amounts of soap and paper products in each restroom.

Outdoor Space: At 2:20 pm., LPA Urena observed the Outdoor space. Backyard has a covered outdoor area equipped with furniture in good repair for residents’ use. There were no bodies of water noted. Side gate is unlocked.

Facility Records: At 3:00 p.m., LPA Urena reviewed records. Files are in good order, and meet
requirements.

LPA Urena observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate

No citations were issued. Exit interview was conducted, the report was reviewed with the administrator and a copy of the report was provided. Signatures were obtained.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022

LIC809 (FAS) - (06/04)

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