195850430-3-21-2024-29-AS-CYEE-D3L277-20240321170815

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850430
Report Date: 03/21/2024
Date Signed: 03/21/2024 05:08:27 PM

Document Has Been Signed on 03/21/2024 05:08 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ANGELS HANDS SENIOR LIVING		FACILITY NUMBER:	195850430
ADMINISTRATOR:	GHUKASYAN, MARINE		FACILITY TYPE:	740
ADDRESS:	14819 VALERIO STREET		TELEPHONE:	(818) 679-4442
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY:	6	CENSUS: 0	DATE:	03/21/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Marine Ghukasyan, Applicant		TIME COMPLETED:	05:15 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) Christine Yee conducted an announced Prelicensing and Component III visit to inspect the physical plant to ensure that the home met Title 22 requirements. The complete CARE Inspection Tool was utilized. LPA Yee met with Marine Ghukasyan, Applicant. Also present during the inspection was Gevorg George Gevshenyan, family member. The home is a single storey family home consisting of a living room, dining room, family room, kitchen, 4 bedrooms of which one will be used for live-in staff and as an office, 2 full bathrooms and a attached garage. The facility is fire cleared for 5 NON-AMBULATORY and 1 BEDRIDDEN residents. Bedroom #2 is the room designated for bedridden use. The following was observed on today's visit: The living room was observed with a piano, a bench and a coffee table. Fire place was capped off but does not have a fire screen. The dining room was observed with a large table and 8 chairs. The family room was furnished with a leather sofa, love seat, arm chair, foot stool, a little armchair, coffee table and television. The fireplace did not have a fire screen. The sliding glass door was equipped with an operable auditory device. The top of screen door was observed to be separated from the frame and needs to be fixed The kitchen is equipped with a stove, dishwasher, coffee machine and microwave. There was sufficient non-perishable foods observed for a minimum of 7 days. No perishable foods were purchased on today's visit. The Applicant was advised that perishable foods for a minimum of 2 days must be purchased prior to the acceptance of the first resident. The following was observed: 20 dinner plates, 12 bowls, 8 cups, 6 tall glasses, 6 short glass, 7 salad plates, 8 saucers, 3 serving bowls, 12 forks,

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

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: ANGELS HANDS SENIOR LIVING	FACILITY NUMBER: 195850430
	VISIT DATE: 03/21/2024

NARRATIVE

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12 knives, 12 tablespoons and 12 teaspoons were observed. Also observed were sufficient pots and pans.
The staff room/office located behind the kitchen was equipped with a full size bed, dresser, desk, little refrigerator for the storage of medications. The first aid cabinet and first aid manual was stored in the room. The auditory device on the outside exit door was tested and was operational.
Bedroom #1, located to the left of the facility was furnished with 2 beds, 2 night stands, 2 lamps, 2 chairs, one shared dresser and a closet. The following was observed on the 2 beds were, a mattress cover, a fitted sheet and a comforter. No blankets or flat sheets or window screens were observed. Window has blinds
The common bathroom contained a walk in shower, toilet and a sink. A grab bar and non-skid mat was observed. Water temperature was tested and it initially read 122.50 and re-tested at 2:56pm and it read 127.3 degrees Fahrenheit.
Bedroom #2, designated as the bedridden room for 1 was furnished with 2 beds, 2 chairs, 2 night stands, 1 shared dresser, 2 lamps and a closet. Beds had a mattress cover, fitted sheet and a comforter. No blanket or flat sheet was observed. The auditory device on the outside exiting door was tested and was operational. Located outside the door was a ramp.
Bedroom #3 was furnished with 2 beds, 2 night stands, 2 lamps, 1 shared dresser, 2 chairs and a closet. The beds were observed with a mattress cover, fitted sheet and a comforter. 1 blanket was observed in the closet. Located inside the room is a private bathroom equipped with a tub, a shower stall, a toilet and a vanity with a sink. Grab bars and non-skid mat was observed in the tub and by the toilet. The shower was missing a grab bar. The water temperature was tested and initially read 125 degrees Fahrenheit at 1:49pm and was re-tested at 3:01pm and it read 125.2 degrees Fahrenheit.
The following linens were observed in the cupboard located by the front door: 12 bath towels, 16 face towels and hand towels, 18 flat sheets, 18 fitted sheets and 18 pillow cases. No additional blankets were observed.
All the windows have blinds for privacy
The facility has 2 fire extinguishers purchase on 2/3/24. One is located in the kitchen and the other by the front door.
The two carbon monoxide detectors are located in the hallway of the resident bedrooms. One of the carbon monoxide detector is hard wired with the smoke detectors.
The smoke detectors were tested and were operational. The facility also has a pull alarm system

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

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: ANGELS HANDS SENIOR LIVING	FACILITY NUMBER: 195850430
	VISIT DATE: 03/21/2024

NARRATIVE

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located by the front door with alarms located by the common bathroom and inside bedroom #3.
Per tour of the enclosed backyard, an umbrella with 6 chairs were observed for resident use. Backyard and front yared was observed to be clean. The 2 trash cans stored in the front yard y were observed to be tightly sealed and the other three were on the street due to trash pick up.

The following corrections need to be made prior to licensure:

The thermostat on the water heater needs to be adjusted so that the water temperature is within 105 -120 degrees Fahrenheit
blankets need to be purchased and made available for resident use.
a grab bar needs to be installed in the shower stall located in the private bathroom
a Long Term Care Ombudsman poster needs to obtained and posted
the complaint poster that meets Title 22 size requirements of 20" x 26"
the water stain on the living room ceiling needs to be painted.
the fire place needs to made inaccessible to the residents. A fire screen will meet this requirement.
the sliding screen door of the family room needs to be repaired.
a window screen needs to be placed on the window located in bedroom #1

The following must be completed once the facility is licensed:

liability insurance that meets Title 22 requirements will be purchased
perishable foods for a minimum of 2 days will be purchased prior to the acceptance of the first resident.

Once all the corrections have been completed, the Applicant will notify LPA Yee so that a return visit may be conducted to clear the facility.

COMPONENT III was conducted Marine Ghukasyan and Gevorg Gevshenyan.

Exit interview was conducted.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

LIC809 (FAS) - (06/04)

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