195850285-1-18-2023-29-AS-ECAS-CN7SUT-20230118131139

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850285
Report Date: 01/18/2023
Date Signed: 01/18/2023 01:12:21 PM

Document Has Been Signed on 01/18/2023 01:12 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:	FALLBROOK ASSISTED LIVING		FACILITY NUMBER:	195850285
ADMINISTRATOR:	ASATRYAN, YULIYA		FACILITY TYPE:	740
ADDRESS:	5504 FALLBROOK AVENUE		TELEPHONE:	(818) 395-9535
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 5	DATE:	01/18/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Yuliya Asatryan		TIME COMPLETED:	01:20 PM

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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility announced at 11:00 a.m. to conduct a pre-licensing inspection. The LPA met with Administrator Yuliya Asatryan. This is a change of ownership application from A Heavenly Haven, Inc (#197605522) to Fallbrook Assisted Living (#195850285). The current capacity is for six (6) residents, the facility currently has five (5) residents. The fire clearance was granted on 08/4/2022; in which all bedrooms were cleared for bedridden, but only one (1) at a time. Applicant successfully completed Component II on 08/29/2022. Applicant successfully completed Component III on 1/18/2023.

At 11:35 a.m., the LPA toured the physical plant areas inside and outside with the applicant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen knives are stored locked and inaccessible in the cabinet. The supply of perishable and nonperishable food is adequate. The supply of dishes is adequate. Appliances in the kitchen were clean and all appeared functional. There is an adequate supply of emergency food.

BEDROOMS: There are six (6) bedrooms in the facility; the facility has five (5) bedrooms for resident use, and one (1) staff room. The staff room is kept locked. All rooms have direct access to the outside. Lighting in the rooms appeared adequate. All resident rooms and one (1) staff room were set up with beds, nightstands, lamps, chests of drawers, chairs, TV’s and closet space.

BATHROOMS: There are two (2) full bathrooms both located in the main hallways designated for, residents, staff and guests. The showers are equipped with nonskid surfaces and available nonskid mats. Grab bars were observed in the bathrooms. Hot water temperature measured at 110.8 degrees Fahrenheit.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

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: FALLBROOK ASSISTED LIVING	FACILITY NUMBER: 195850285
	VISIT DATE: 01/18/2023

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COMMON AREA: The common areas were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment in the living room area. The facility smoke alarm system is hard wired; the smoke detectors were operable at the time of the visit. There are two (2) fire extinguishers which were fully charged and last serviced March 31, 2022. There is a functioning telephone on the premises. Emergency exiting plans/sketch are posted on the facility living room wall. Emergency telephone numbers are posted on the facility living room wall. Other required postings are posted in the dining room area and upon entry into the facility.

MEDICATIONS: Medications are located in a locked cabinet located in the kitchen which is locked and inaccessible to residents in care. The first aid supplies were complete, including a first aid manual.

FILES: Resident and staff records are stored in a small office corner located in the facility dining room.

LAUNDRY: The laundry area is located in the hallway. All detergents and cleaning supplies are locked and inaccessible to residents in care.
EXTERIOR: The exterior passageways were clean and clear of any obstructions. There is a covered patio area in the backyard with tables and chairs for resident use. There are no bodies of water noted on the premises. The back and sides of the house are separated from the front yard by gates at the north and south side passageways, both gates have self-latching mechanisms. There is a front yard gate with self-latching mechanisms. There is no driveway gate. The facility has an de-attached storage used for storage and emergency supplies, food. There are no other structures on the property.
INFECTION CONTROL: The facility has a central entry point for symptom screening and sanitation station for staff, residents, and visitors. The facility has an adequate supply of PPE and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

Physical plant is in compliance with Title 22 regulations at this time.

This report will be sent to the Centralized Application Bureau (CAB). The CAB Analyst will notify the applicant when the license has been approved. The applicant is aware that they are unable to operate and accept residents until they have been notified that the license has been approved by the CAB Analyst. Failure to comply could affect approval of the license. Exit interview conducted and report issued via email.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

LIC809 (FAS) - (06/04)

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