<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850166
Report Date: 05/05/2022
Date Signed: 05/05/2022 02:57:00 PM

Document Has Been Signed on 05/05/2022 02:57 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. #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: 4DATE:
05/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Ovsanna Khayalyan, Licensee TIME COMPLETED:
03:00 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
At 1:12 p.m., Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. LPA was greeted and screened by staff. At 1:35 p.m., the Licensee Ovsanna Khayalyan arrived at the facility. This annual had a specific emphasis on infection control practices and procedures.

At 1:25 p.m., the 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.

KITCHEN: At 1:25 p.m., the LPA observed the kitchen/dining area. Knives are stored in a locked drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 1:43 p.m., hot water measured at 106.1-degree Fahrenheit. Medications and first aid kits are located in a locked cabinet. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away.

COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished. The LPA observed the fire extinguisher to be fully charged and last purchased on 05/05/2022. Flashlights were observed throughout the facility. Upon entry, signs are posted to promote handwashing, cough/sneeze etiquette, and physical distancing. At 1:43 p.m., fire alarms and carbon monoxide detectors were tested and functioned properly.

BEDROOMS: The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level.

Continued on LIC 809-C.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2022
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
VISIT DATE: 05/05/2022
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
26
27
28
29
30
31
32
RESTROOMS: The facility has two restrooms, one for resident use and one for staff use. The resident restroom is relatively clean and sanitary and in operating condition with grab bars and non-skid mats. The laundry units are located inside the staff restroom which remains locked. At 1:44 p.m., hot water measured at 106.0-degree Fahrenheit. Night lights were present in the hallway.

OUTDOOR SPACE: At 1:38 p.m., the LPA observed the backyard, which has a covered outdoor area for resident use. There is a gate on the side of the house that is designated for an emergency exit. Passageways were free and clear from obstruction.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Licensee regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station. LPA observed a 30-day 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 has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies were observed at this time. Exit interview conducted with the Licensee. Report issued and a copy of the report was emailed.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2