195850089-2-6-2024-29-AS-SURA-D282XD-20240206164656

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850089
Report Date: 02/06/2024
Date Signed: 02/06/2024 04:47:27 PM

Document Has Been Signed on 02/06/2024 04:47 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 N.ASC, 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: 6	DATE:	02/06/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Gohar Khachatryan		TIME COMPLETED:	03:05 PM

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Licensing Program Analyst (LPA) Sandra Urena, arrived at the facility unannounced to conduct a required annual inspection. LPA Urena arrived at the facility at 11:00 a.m. and was greeted by the staff. Staff call the administrator to announce the LPA’s visit. The administrator arrived shortly thereafter, and the LPA explained the reason for the visit.

At 11:25 a.m., LPA Urena and the administrator conducted a tour of the inside and outside the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature of 70 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was last serviced on 12/01/2023. The LPA observed required postings throughout the common space.

KITCHEN: 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.

BEDROOMS: were observed to be furnished appropriately with appropriate furnishings, and sufficient lighting. Linens are clean and in good condition.

BATHROOMS: Bathrooms were observed to be clean; shower area was in clean condition with grab bars and a non-skid mat available. Paper towels were available for drying hands. Hand washing signs were displayed, and sufficient amounts of soap and paper products in each restroom.

Continues on LIC 809C...

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: MARY ELLEN HOMES	FACILITY NUMBER: 195850089
	VISIT DATE: 02/06/2024

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OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for resident use. There is a side gate for client use and is single-latched. No bodies of water noted. The washer and dryer are in a locked closet between bedrooms 2 and 4. Cleaning supplies and disinfectants are kept in locked in the laundry closet.

RECORDS: Records review began at 1:00 p.m., Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 1:45 p.m.; medications are centrally stored and locked in a cabinet; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

INFECTION CONTROL: The facility has 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 LPA reviewed the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2024

LIC809 (FAS) - (06/04)

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