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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850166
Report Date: 09/22/2021
Date Signed: 09/22/2021 02:52:00 PM

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:AAA QUALITY RESIDENTIAL CARE FACILITYFACILITY NUMBER:
195850166
ADMINISTRATOR:KIRAKOSYAN, ELENFACILITY TYPE:
740
ADDRESS:7843 STANSBURY AVE.TELEPHONE:
(323) 485-4851
CITY:PANORAMA CITYSTATE: CAZIP CODE:
91402
CAPACITY:6CENSUS: 2DATE:
09/22/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ovsanna KhayalyanTIME COMPLETED:
03:00 PM
NARRATIVE
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At 10:00 a.m. Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility to conduct a Post Licensing visit. LPA was greeted and screened by staff Ovsanna Khayalyan. Administrator Elen Kirakosyan was unavailable at the time of the visit and authorized staff Ovsanna Khayalyan to sign the report.

At 10:17 a.m. LPA, along with staff, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Today's evaluation included but was not limited to building and grounds, resident rooms, bathrooms, common areas, personal accommodations, and food supplies. There is an adequate amount of perishable and nonperishable foods. LPA observed fire extinguisher fully charged and last purchased on 04/30/2021. Centrally stored medicines are kept in a locked kitchen cabinet. First Aid kit is complete. Grab bars and non-skid mats were present in the bathroom. LPA observed appropriate and sufficient lighting in each room. At 10:59 a.m. hot water for the kitchen measured at 105.2-degree Fahrenheit. At 11:00 a.m. hot water for resident restroom measured at 107.3-degree Fahrenheit. Hygiene items are being provided. At 1:59 p.m. the smoke alarms and carbon monoxide detectors were tested in the common areas and resident bedrooms and they were all operational. LPA observed disaster plan posted near the living room area. LPA observed COVID-19 postings throughout the facility. LPA observed a 30-day supply of PPE.

Between 10:27 a.m.- 11:03 a.m. LPA reviewed resident medications and records. One (1) out of two (2) residents records did not have a pre-admission appraisal completed. At 11:33 a.m. LPA reviewed of staff records.
The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. Report issued and a copy of the report and appeal rights was provided via email.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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: AAA QUALITY RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 195850166
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/29/2021
Section Cited

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87457Pre-Admission Appraisal - General(c)Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison...
This requirement is not met as evidenced by:
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Based on record review, the licensee did not comply with the section cited above in which 1 out of 2 residents did not have a pre-admission appraisal completed which poses a potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2021
LIC809 (FAS) - (06/04)
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