195850227-3-10-2024-29-AS-MARO-D38VQU-20240310163856

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850227
Report Date: 03/10/2024
Date Signed: 03/10/2024 04:39:30 PM

Document Has Been Signed on 03/10/2024 04:39 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:	AMERIHOME, INC		FACILITY NUMBER:	195850227
ADMINISTRATOR:	SARGSYAN, JASMINE H		FACILITY TYPE:	740
ADDRESS:	17019 MARLIN PL		TELEPHONE:	(818) 441-3590
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91406
CAPACITY:	6	CENSUS: 6	DATE:	03/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Jasmine Sargsyan		TIME COMPLETED:	04:45 PM

NARRATIVE

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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced for a required one-year annual inspection today at 12:30PM. The last annual conducted at this facility was on 02/03/2023. When the LPA arrived, there were two (2) staff and six (6) residents present. The LPA met with staff and advised them of the visit. Staff called the Administrator, and at this time, the reason for the visit was explained. The Administrator, Jasmine Sargsyan arrived at 1:15PM. Entrance interview.

At 1:17PM, the LPA along with the Administrator 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. The following was noted:

KITCHEN: The LPA inspected the kitchen/food service area at 1:28PM. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Food labels were inspected and checked for dates and expiration dates and food labels had expiration date clearly marked. The knives and sharps are stored in a locked drawer inaccessible to residents in care. At 1:33PM, the hot water temperature was measured in the kitchen sink, and it measured 114.9 degrees Fahrenheit.

COMMON AREAS: At the time of the visit, the living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. At 1:40PM, the smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was observed to be in compliance and newly purchased on 07/26/2023.

Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2024

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMERIHOME, INC	FACILITY NUMBER: 195850227
	VISIT DATE: 03/10/2024

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Continued from LIC 809...

The LPA observed required postings throughout the common space. Night lights were present in the hallways. Auditory alarms were observed working at the time of the visit. There is a working telephone on premises.

LAUNDRY ROOM: LPA observed a laundry room with a washer and a dryer. Laundry detergents were observed inside a locked cabinet in the laundry room.

OUTDOOR AREA: The backyard has a covered patio area equipped with furniture for resident use. Emergency exits and passageways were observed free of obstruction. There were two (2) side gates with self-latching mechanisms. No bodies of water were noted at the time of the visit.

GARAGE: The garage is attached and observed locked at the time of the visit. There is one (1) additional refrigerator with perishable food in good condition. LPA observed additional Personal Protection Equipment (PPE). Extra cleaning supplies were observed inaccessible to residents.

BEDROOMS: There are five (5) resident bedrooms and one (1) staff bedroom. The LPA observed the resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

RESTROOMS: There are three (3) resident restrooms. Restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with liquid soap and paper towels; towels and washcloths are not shared. The hot water temperature was measured in all bathrooms; the first bathroom measured 114.4 degrees Fahrenheit at 1:18PM; the second bathroom measured 118.0 degrees Fahrenheit at 1:20PM; and the third bathroom measured 112.4 degrees Fahrenheit at 1:26PM.

RECORDS: Records review began at 1:56PM; six (6) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. All records were in order.

Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2024

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: AMERIHOME, INC	FACILITY NUMBER: 195850227
	VISIT DATE: 03/10/2024

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Continued from LIC 809C...

Two (2) personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were complete.

The current Administrator’s file was also reviewed, and it was complete. Administrator’s certificate is active and expires on 01/07/2025

At the time of the visit, LPA obtained copies of current LIC 500, Infection Control Plan, and Limited Liability Insurance.

The last emergency disaster drill took place on 12/12/2023.

MEDICATIONS: Medications review began at approximately 3:10PM; medications are centrally stored in a locked closet by Room #1. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications are properly documented on the centrally stored medications and destruction record.

Exit interview conducted. No deficiencies cited. Report was reviewed and a copy was issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2024

LIC809 (FAS) - (06/04)

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