195850245-7-15-2022-29-AS-SURA-CGCT8K-20220715143026

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850245
Report Date: 07/15/2022
Date Signed: 07/15/2022 02:31:23 PM

Document Has Been Signed on 07/15/2022 02:31 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:	SG CARE		FACILITY NUMBER:	195850245
ADMINISTRATOR:	HARUTYUNYAN, ZARUHI		FACILITY TYPE:	740
ADDRESS:	7920 VANTAGE AVENUE		TELEPHONE:	(818) 397-2656
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY:	6	CENSUS: 0	DATE:	07/15/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Zaruhi Harutyunyan		TIME COMPLETED:	12:56 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	The pre-licensing visit was conducted by Licensing Program Analyst (LPA), Sandra Urena. The LPA arrived at the facility at 9:30 a.m., and met with applicant Zaruhi Harutyunyan. This is a new facility application for five non-ambulatory residents, and one bedridden resident. At 9:45 a.m., the LPA, and the applicant 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. KITCHEN: The supply of dishes is adequate. Appliances in the kitchen were clean and all appeared functional. Kitchen, and house cleaning supplies will be stored in locked cabinet under the kitchen sink. Hot water temperature was recorded at 108.8 degrees Fahrenheit. Trash cans have a tight-fitting lid. There were no pesticides or toxins stored near food, or preparation area. BEDROOMS: There are three bedrooms for residents' use, each room has double occupancy. Bedroom #1 is licensed for one bedridden resident, and one non-ambulatory resident. Bedrooms #2 and #3 are for double occupancy. Lighting in the rooms appeared adequate. All bedrooms had adequate closet, and drawer space for clothing, and personal belongings. Continued in LIC 809C...

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022

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: SG CARE	FACILITY NUMBER: 195850245
	VISIT DATE: 07/15/2022

NARRATIVE

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BATHROOMS: Two bathrooms (1 &2) are fully stocked with paper towels, and liquid hand soap. The shower has non-skid surface. Hot water temperature was recorded at 111.6 degrees Fahrenheit. Hand washing signs were visible and posted. Bathroom #1 is designated for staff use. The washer and dryer are located in this bathroom. The clearance between the bathroom door, and the washer is about one inch (1”) at the point when both(door and washer) meet, once the door is fully open the door clears space for a person to pass through. At the time of inspection, the LPA detected a faint odor of gas. The dryer in this bathroom is gas operated. The applicant was advised about the odor, and to have the Gas Company check for any gas leaks. Bathroom #2 is designated for residents and is fully equipped with handlebars, and nonskid surfaces.

COMMON AREAS: The common areas were appropriately furnished, and the lighting was adequate. There
are televisions, and other entertainment equipment in the living room area, and bedrooms.

Residents, and staff records will be stored in a filing cabinet in the common area. Medications will be stored in locked cabinet found in the common area. The first aid supplies were complete, including a thermometer,
and a current version of a first aid manual.

The facility’s smoke/carbon monoxide alarm systems are hard wired. The alarm systems are only installed in the hallway, and bedrooms, but not in the kitchen/common areas. All rooms were tested, and all smoke/carbon monoxide alarm systems were in operating condition. The applicant was advised to install the fire/carbon monoxide alarm in the common/kitchen area. A fire extinguisher is properly charged, and is located mounted on the wall in the common area.

The laundry area is located in the bathroom #1 (see BATHROOMS above). The supply of extra bed, and bath linens is adequate. There is a functioning land line telephone on the premises. Infection control, and other posters are posted throughout the facility and hallways.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022

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: SG CARE	FACILITY NUMBER: 195850245
	VISIT DATE: 07/15/2022

NARRATIVE

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The exterior passageways were clean, and clear of any obstructions. The patio front is furnished with outdoor furniture for residents’ use, and shade is available. The building has a central entrance for residents, and visitors. Fire emergency gates are clear of obstructions.

Pre-Licensing is incomplete with deficiencies to be resolved. During the inspection, the LPA, and applicant observed the following corrections needed, prior to being licensed:

1. Applicant will install smoke/carbon monoxide detector in the common area/kitchen area.
2. Add signal systems to bedroom #1 for bedridden resident, and one non-ambulatory resident; and for the four (4) non-ambulatory residents in bedrooms #2 and 3.
3. Add lock to cabinet under sink to keep cleaning supplies.
4. Obtain adequate flashlights for emergency, and batteries locked.
5. Obtain refrigerator thermometers to ensure refrigerator, and freezer temperatures are at a safe level.
6. Add a seven day supply of non-perishable food to the pantry.

The applicant completed Component III Orientation.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview was conducted and reviewed with applicant Zaruhi Harutyunyan. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022

LIC809 (FAS) - (06/04)

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