195850245-8-23-2023-29-AS-SURA-CUYSG7-20230823135128

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850245
Report Date: 08/23/2023
Date Signed: 08/23/2023 01:52:25 PM

Document Has Been Signed on 08/23/2023 01:52 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: 6	DATE:	08/23/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:31 AM
MET WITH:	Zaruhi Harutyunyan		TIME COMPLETED:	02:32 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) Sandra Urena arrived at the facility unannounced to conduct a required annual visit at 10:10 a.m. The LPA was greeted by staff and informed them of the reason for the visit. Administrator Zaruhi Harutyunyan. arrived shortly thereafter. At 10:45 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. The facility was licensed for five non-ambulatory residents, and one bedridden resident. 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 degrees 111.6 Fahrenheit. Hand washing signs were visible and posted. Bathroom #1 is designated for staff use. Bathroom #2 is designated for residents and is fully equipped with handlebars, and nonskid surfaces. 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: 08/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023

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: SG CARE	FACILITY NUMBER: 195850245
	VISIT DATE: 08/23/2023

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

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. The first aid supplies were complete, including a thermometer, and a current version of a first aid manual was found in the kitchen area. The facility’s smoke/carbon monoxide alarm systems are hard wired. All rooms were tested, and all smoke/carbon monoxide alarm systems were in operating condition. A fire extinguisher is properly charged and is located mounted on the wall in the common area. 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.

The exterior passageways were clean, and clear of any obstructions. The front patio 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.

RECORDS: Records review began at 12:30 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate additional training. All files were in order.

MEDICATIONS: Medications review began at 1:30 p.m. medications are centrally stored and locked in a cabinet in the common area. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

INFECTION CONTROL: The facility has an adequate 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 LPAs discussed the new PIN changes regarding infection control.

The LPA obtained the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster
No deficiencies cited at this time. Exit interview conducted. 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: 08/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2