195850290-10-19-2023-29-AS-SURA-CWRRZ9-20231019132734

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850290
Report Date: 10/19/2023
Date Signed: 10/19/2023 01:28:19 PM

Document Has Been Signed on 10/19/2023 01:28 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:	MATEVOSIAN HOME		FACILITY NUMBER:	195850290
ADMINISTRATOR:	MATEVOSIAN, RAFAEL		FACILITY TYPE:	735
ADDRESS:	7500 BELLINGHAM AVE		TELEPHONE:	(818) 522-2222
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY: 4		CENSUS: 4	DATE:	10/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:08 AM
MET WITH:	Rafael Matevosian		TIME COMPLETED:	01:30 PM

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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual inspection. The LPA met with the facility representative and explained the reason for the visit.

The LPA and the staff representative toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen knives are stored locked, and inaccessible to residents. 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. The hot water temperature in the kitchen measured 113.5 degrees Fahrenheit. The fire extinguisher is mounted by dining room area and was last serviced on 09/05/2023. The first aid supplies were available, including a first aid manual, which is located by the kitchen area.

BEDROOMS: The facility has five (5) bedrooms, four bedrooms for residents, and one for staff. Bedrooms are single occupancy. All residents’ bedrooms are furnished appropriately with clean linens, furnishings, and sufficient lighting.

BATHROOMS: There are two (2) bathrooms designated for residents’ use. The shower is equipped with a nonskid surface. Grab bars were observed in the bathroom. The hot water temperature in the bathroom on the first floor measured at 112.6 degrees Fahrenheit, and second floor at 112.7 degrees Fahrenheit.

Continues on LIC809-C

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

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

FACILITY NAME: MATEVOSIAN HOME	FACILITY NUMBER: 195850290
	VISIT DATE: 10/19/2023

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COMMON AREA: The common areas were appropriately furnished, and the lighting was adequate. The common areas, walls, flooring and furniture were checked for cleanliness and were found to be in good condition. Required postings were observed in the hallway area. Smoke detectors and carbon monoxide detector were tested and operational at the time of the visit.

Emergency exiting plans/sketch, emergency telephone numbers, and other required postings are posted in the hallway and living room area.

LAUNDRY: The laundry area is in a room towards the recreation room.

RECORDS: Records review began at …., 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 training. All files were in order. Resident and staff records are stored in the closet located in the hallway, which was observed to be locked and inaccessible to residents in care.

MEDICATIONS: Medications review began at ….. 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. Medications are stored in the closet located in the hallway, and was observed to be locked, and inaccessible to residents in care.

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 LPA reviewed 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.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

LIC809 (FAS) - (06/04)

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