195850245-8-21-2024-29-AS-TBYE-D8CT8C-20240821143007

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850245
Report Date: 08/21/2024
Date Signed: 08/21/2024 02:31:20 PM

Document Has Been Signed on 08/21/2024 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
WOODLAND HILLS N.ASC, 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:	08/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Zaruhi Harutyunyan		TIME COMPLETED:	02:45 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 Analysts (LPAs) Trevor Byrne and Emily Peraldi arrived at the facility unannounced to conduct a required annual visit at 09:35 AM. LPAs met with facility staff who contacted the facility administrator Zaruhi Harutyunyan. Facility administrator arrived to the facility at 09:36 AM Entrance interview conducted and the reason for the visit was explained. Beginning at 09:37 AM, the LPAs, along with facility administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: The LPAs observed the kitchen area to be clean. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPAs observed a secured cabinet contain knives and other sharp objects. The LPAs observed the fire extinguisher to be fully charged and purchased on 06/12/2024. BEDROOMS: There are three (3) bedrooms in the facility; all are designated for resident use, and all are designated as dual occupancy rooms. LPAs and facility administrator toured all three (3) resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Bedroom number one (1) is approved for a bedridden resident. Auditory alarms were observed to be functional on bedroom one’s (1’s) exit door. BATHROOMS: There are two (2) bathrooms at the facility. One (1) is designated as a resident restroom and one (1) is primarily used as a staff restroom. Both restrooms were observed to be clean and in good repair and all were equipped with nonskid surfaces. Grab bars were observed in the resident restroom shower and by the resident toilet, all were properly secured. The water temperature was measured between 110.1 and 113 degrees Fahrenheit, which is in compliance with regulation. Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor Byrne	TELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SG CARE	FACILITY NUMBER: 195850245
	VISIT DATE: 08/21/2024

NARRATIVE

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Continued from LIC 809-C

COMMON AREAS: This includes the living room. LPAs observed the living room to be clean and properly furnished at the time of the visit. Smoke detectors and carbon monoxide detectors were tested at 10:00 a.m. and were functional at the time of the visit.

OUTDOOR SPACE: The facility has one (1) emergency exit gate, LPAs observed clear passageways for emergency exit use. The facility has adequate seating for resident use. Cameras were observed by the front entrance to the facility. Five (5) sheds were observed to be properly secured, one (1) contained a washer and dryer as well as cleaning products. One (1) shed contained an adequate supply of emergency food and water. The remaining three (3) sheds contained additional supplies and cleaning chemicals.

RECORD REVIEW: Record review began at 10:05 a.m. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, TB tests, consent forms, and personal rights. Five (5) staff files were reviewed. All staff files contained the required documents and trainings. Six (6) resident files were reviewed. All resident files reviewed contained all required documentation. No deficiencies were observed during record review.

MEDICATION REVIEW: Medications are stored centrally and securely in a filing cabinet located in the living room. Medications for three (3) residents were observed. All medications reviewed were documented properly on their centrally stored medication and destruction record sheet. No deficiencies were observed during medication review.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPAs reviewed the
facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Last emergency disaster drill was conducted 06/26/2024. The facility’s emergency disaster plan is up to date and adequate.

Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor Byrne	TELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SG CARE	FACILITY NUMBER: 195850245
	VISIT DATE: 08/21/2024

NARRATIVE

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Continued from LIC 809-C

INTERVIEWS: LPAs interviewed one (1) staff and five (5) residents. All residents interviewed stated that the food was of good quality and is provided in sufficient amounts. All residents stated that staff treat them well and are attentive to their needs. The staff member interviewed was knowledgeable on their roles and responsibilities, resident rights, the different forms of abuse and the appropriate reporting procedures for suspected abuse.

During today’s visit LPAs obtained a copy of the facility’s updated LIC500, resident roster, and liability insurance.

No deficiencies were cited at the time of the visit. Exit interview conducted. And a copy of the report was provided.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor Byrne	TELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

LIC809 (FAS) - (06/04)

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