195850360-9-9-2024-29-AS-EMOY-D8XT9A-20240909143137

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850360
Report Date: 09/09/2024
Date Signed: 09/09/2024 02:31:51 PM

Document Has Been Signed on 09/09/2024 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:	AY SENIOR CARE INC		FACILITY NUMBER:	195850360
ADMINISTRATOR/ DIRECTOR:	CLAUDIA HESHMATI		FACILITY TYPE:	740
ADDRESS:	6623 VESPER AVE		TELEPHONE:	8184040550
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY: 6		CENSUS: 3	DATE:	09/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:15 AM
MET WITH:	Kevin Kalantarohanian - DESIGNATED PERSON		TIME VISIT/ INSPECTION COMPLETED:	02:35 PM

NARRATIVE

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Licensing Program Analysts (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 10:15 a.m. Upon arrival, LPA Mosley was greeted by staff and called the administrator to inform them of the visit. The administrator arrived shortly thereafter. The LPA met with Designated person Kevin Kalantarohanian and explained the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: The LPA inspected the kitchen/food service area at 11:05 a.m. Knives and sharps were observed in a locked cabinet. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 110.9 degrees Fahrenheit at 11:08 a.m.

COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 11:40 a.m., smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged and purchased on 07/02/2024. The LPAs observed required postings throughout the common space. The last emergency disaster drill took place on 08/28/2024 and are done quarterly. Activities were observed in the common areas.

Report Continued on LIC 809C...

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024

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: AY SENIOR CARE INC	FACILITY NUMBER: 195850360
	VISIT DATE: 09/09/2024

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Report Continued from LIC 809...

RESTROOMS: The two (2) resident restrooms, one (1) shared and one (1) private and were clean, sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured; the first bathroom measured at 106.7 degrees Fahrenheit and the second bathroom measured at 108 degrees Fahrenheit. Both bathrooms were measured between 11:50 a.m. – 12:10 p.m.

BEDROOMS: There are 4 (four) total bedrooms in the facility; two (2) shared two (2) private. Currently all are single occupancy. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

OUTDOOR /BACKYARD /CLOSETS: There is a washer and dryer on premises. Laundry detergent was observed in a locked closet between room one (1) and room two (2). LPA observed an adequate amount of emergency food and water. Cleaning supplies are kept in the locked closet and inaccessible to residents in care. The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. There were no bodies of water noted at the time of the visit.

MEDICATIONS: Medications review began at approximately 12:19 p.m. The medications are locked in a cart adjacent to the kitchen. Medications for three (3) out of three (3) clients were reviewed. Medications reviewed were found to be self administered as prescribed and documented on the centrally stored medication and destruction records.

RECORDS Resident Records were reviewed beginning at 11:17 a.m. and personnel records at 12:01 p.m. three (3) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan.

Report Continued from LIC 809C...

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024

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: AY SENIOR CARE INC	FACILITY NUMBER: 195850360
	VISIT DATE: 09/09/2024

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Report Continued from LIC 809C...

Five (5) personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order.

INTERVIEWS: Two (2) staff interviews were conducted. Three (3) client interviews were attempted. One (1) interview was conducted.

No deficiencies were cited during today’s inspection. Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024

LIC809 (FAS) - (06/04)

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