195850178-10-26-2022-29-AS-EPEI-CKKUR6-20221026154814

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850178
Report Date: 10/26/2022
Date Signed: 10/26/2022 03:48:42 PM

Document Has Been Signed on 10/26/2022 03:48 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:	MONOGRAM VILLA		FACILITY NUMBER:	195850178
ADMINISTRATOR:	KRBASHYAN, AZNIV ANGELA		FACILITY TYPE:	740
ADDRESS:	5536 TYRONE AVE		TELEPHONE:	(818) 808-7792
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91401
CAPACITY:	6	CENSUS: 1	DATE:	10/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Goar Boyadzhyan		TIME COMPLETED:	04:00 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	Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 2:46 p.m., the LPA was greeted and screened by staff. At 3:05 p.m., the LPA spoke with the Administrator over the phone. The Administrator was not available during the time of the visit and authorized staff, Goar Boyadzhyan to sign the report. This annual had a specific emphasis on infection control practices and procedures. At 2:55 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 that the facility is in compliance with Title 22 Regulations. 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. RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. At 3:06 p.m., hot water measured at 112.0-degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels. KITCHEN: The LPA observed the kitchen/dining area. Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 3:02 p.m., hot water measured at 111.7-degree Fahrenheit. Medications and first aid kits are located in a locked cabinet near the kitchen area. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in a cabinet near the kitchen area. The laundry units are located near the kitchen area. Continued on LIC 809-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

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: MONOGRAM VILLA	FACILITY NUMBER: 195850178
	VISIT DATE: 10/26/2022

NARRATIVE

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COMMON AREAS: The LPA observed common areas to be relatively clean and properly furnished. The LPA observed the fire extinguisher to be fully charged and last serviced on 05/25/2022. Signs are posted throughout facility to promote handwashing, and cough/sneeze etiquette. At 3:10 p.m., fire alarms/carbon monoxide detectors were tested and functioned properly.

OUTDOOR SPACE: At 2:57 p.m., the LPA observed the back patio and side patios which have a covered outdoor area for resident use. There is a gate on the side of the house designated for an emergency exit. All outdoor and indoor passageways were kept free of obstruction.

INFECTION CONTROL: During today’s visit, the LPA spoke with the staff 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. The 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. The facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies were observed at this time. Exit interview conducted. Report issued and a copy of the report was provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

LIC809 (FAS) - (06/04)

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