195850349-5-23-2023-29-AS-EPEI-CS4RLT-20230523130741

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850349
Report Date: 05/23/2023
Date Signed: 05/23/2023 01:08:12 PM

Document Has Been Signed on 05/23/2023 01:08 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:	LOVING CARE FACILITY INC.		FACILITY NUMBER:	195850349
ADMINISTRATOR:	NSHANYAN, HASMIK		FACILITY TYPE:	740
ADDRESS:	15107 BURTON ST		TELEPHONE:	(310) 993-2441
CITY:	PANORAMA	STATE: CA	ZIP CODE:	91402
CAPACITY:	4	CENSUS: 0	DATE:	05/23/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:26 AM
MET WITH:	Hasmik Nshanyan		TIME COMPLETED:	01:15 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) Emily Peraldi conducted a pre-licensing visit to the above noted facility at 11:26 a.m. The LPA met with applicant, Hasmik Nshanyan. This is a new facility. A dementia program was included in the plan of operation. A Hospice Waiver has been requested for four (4). The facility is one story. At 11:32 a.m., a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for one (1) ambulatory resident, two (2) non-ambulatory residents and one (1) bedridden resident. Resident Room #1 is the ambulatory only room. The facility has one (1) shared rooms, Room #2. Resident rooms #3 has direct exits to the outside and is approved for bedridden. The facility does not have fire sprinklers. All resident rooms are set up with beds, nightstands, lamps, and closet space. There are chests of drawers and chairs for each room. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. In addition, no bedroom was used as a passageway to another room, bath or toilet. There are no staff rooms and an awake night staff will be present. All rooms were free of odors. All window screens were clean and maintained in good repair. There are two (2) bathrooms in the facility, one in the hallway and one in Room #1. The resident bathrooms have a shower and have non-skid materials. Both of the restrooms have shower with grab bars. The hot water temperature was tested in the bathrooms and the kitchen and was found to be within the range of 105F and 120F. The hot water temperature was measured as follows: bathroom #1= 116.5F, bathroom #2 = 115.8F and the kitchen =115 *F. Resident and staff records will be stored in a locked kitchen cabinet. Medications will be centrally stored in a locked cabinet in the kitchen. The first aid supplies were complete. Continued on LIC 809-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

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: LOVING CARE FACILITY INC.	FACILITY NUMBER: 195850349
	VISIT DATE: 05/23/2023

NARRATIVE

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Kitchen knives are stored in a locked drawer in the kitchen. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of nonperishable food will be adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. The trash can has tight fitting lid for the kitchen. Kitchen, laundry and house cleaning supplies are stored in a locked kitchen cabinet as well in two locked closets. No flies or other vermin were observed.

The common areas were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment, games and/or activity supplies in the living room and dining area. There was sufficient space to accommodate both indoor and outdoor activities. Night lights are maintained in hallways and passageways to nonprivate bathrooms. Night lights are also present throughout the facility and rooms. All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. There is not a fireplace in the living room. Alarms on all exterior doors were engaged at the time of visit and functional. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included flashlights. The applicant will have batteries prior to licensure. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit.

The facility smoke alarm system is hard wired. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. There is one fire extinguisher, and it was fully charged and did not exceed the expiration date.The laundry units are located in a hallway. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in one of the restroom closets. Extra incontinence supplies are stored in the restroom closet. There will be a functioning telephone on the premises. Required postings are located near the front entrance.

The exterior passageways were clear of any obstructions. There is a covered patio area at the front of the house. There is patio furniture for resident use. The entire property is fenced. There is an accessory dwelling unit (ADU) behind the house, but the ADU is not part of the license. The ADU is separated from the front house by a gate. There are not any bodies of water on the premises at the present time. Continued on LIC 809-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

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: LOVING CARE FACILITY INC.	FACILITY NUMBER: 195850349
	VISIT DATE: 05/23/2023

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At 12:14 p.m., Comp III was completed.

No correction were needed at this time.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC809 (FAS) - (06/04)

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