195850298-1-16-2024-29-AS-SURA-CZJMA7-20240116082550

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850298
Report Date: 01/13/2024
Date Signed: 01/16/2024 08:26:23 AM

Document Has Been Signed on 01/16/2024 08:26 AM - 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:	LAURELGROVE BOARD AND CARE		FACILITY NUMBER:	195850298
ADMINISTRATOR:	TADEVOSYAN, LUSINE		FACILITY TYPE:	740
ADDRESS:	8221 LAURELGROVE AVE		TELEPHONE:	(818) 355-2632
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY:	6	CENSUS: 5	DATE:	01/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:			TIME COMPLETED:	02:55 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 an annual inspection. The LPA was greeted by staff and called the Administrator Lusine Tadevosyan. The LPA communicated with the administrator and stated that they were not available, and the staff designated by the facility would arrive shortly. The staff Anahit Ohanyan arrived shortly thereafter, and the LPA and explained the reason for the visit. The LPA, and the staff 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: A seven-day supply of non-perishable food was available. The supply of dishes is adequate. Appliances in the kitchen were clean and all appeared functional. House cleaning supplies will be stored and locked in the cabinet under the sink. Trash cans have a tight-fitting lid. There were no pesticides or toxins stored near food, or preparation area. COMMON AREAS: The common areas were appropriately furnished, and the lighting was adequate. There is a television in the living room 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 near the main door entrance, and mounted on the wall in the kitchen area. The fire extinguisher was last purchased on 01/10/204. The laundry area room is located outside. The supply of linens is sufficient to permit changing weekly or more often as needed to ensure use of linens at all times. Required posters are posted in the dining room area. BEDROOMS: Facility has five (5) bedrooms for resident use. There is no bedroom available for staff use. Bedrooms 2, 3, 4 and 5 are for single occupancy. Bedroom #1 is designated as a shared bedroom. Either bedroom #1, or #2 are approved for one (1) bedridden resident. Lighting in the rooms appeared adequate. All bedrooms had adequate closet and drawer space for clothing, and personal belongings. Continues on LIC809C ...

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2024

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: LAURELGROVE BOARD AND CARE	FACILITY NUMBER: 195850298
	VISIT DATE: 01/13/2024

NARRATIVE

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BATHROOMS: The facility has four bathrooms. Bathrooms are private, located inside the bedrooms and are for residents’ use, are fully stocked with paper towels, and liquid hand soap. The showers have non-skid surface mats. Hot water temperatures were recorded in Fahrenheit degrees as follows:109.2 degrees for bathroom in bedroom #1, 110.2 degrees for bathroom in bedroom #2, 115.5 degrees in bathroom for bedrooms #4 and #5, and 116.2 degrees for bedroom #3. Hand washing signs were visible and posted. The bathroom designated for staff use, is located outdoors inside the laundry room.

OUTDOOR: 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. The facility has a gated pool with a locked padlock and is inaccessible to residents.

RECORDS: Records review began at 12:09 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 training. All files were in order.

MEDICATIONS: Medications review began at 1:45 p.m.; medications are centrally stored and locked in a cabinet in the kitchen 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 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.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2024

LIC809 (FAS) - (06/04)

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