195850501-7-16-2024-29-AS-CYEE-D78VQP-20240716163840

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850501
Report Date: 07/16/2024
Date Signed: 07/16/2024 04:38:55 PM

Document Has Been Signed on 07/16/2024 04:38 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:	BELLAIRE SENIOR CARE		FACILITY NUMBER:	195850501
ADMINISTRATOR:	GEVORGYAN, ERNA		FACILITY TYPE:	740
ADDRESS:	6523 BELLAIRE AVENUE		TELEPHONE:	(818) 987-1115
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY:	6	CENSUS: 4	DATE:	07/16/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:03 AM
MET WITH:	Eva Terzian, Applicant		TIME COMPLETED:	04:45 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 the facility. The complete CARE Inspection Tool was used on this visit. LPA Yee conducted the visit with Erna Gevorgyan, Administrator, Eva Terzian, Applicant and David Abramyan, Staff. The facility is a single storey family home consisting of a living room, dining room, kitchen, 3 bedrooms, 2 full bathrooms and a car port. The facility is fire cleared for 5 non-ambulatory and 1 bedridden resident. Bedroom #1 is designated for bedridden use for the one resident. Located in the back of the facility is an ADU with it's own address of 6521 Bellaire Avenue that is rented out. The following was observed on today's visit: the living room and dining room are furnished with the appropriate furniture and sitting for 6 residents the kitchen is equipped with a refrigerator, dishwasher, toaster oven, microwave and coffee maker. sufficient plates, cups and bowls were observed. sufficient utensils were observed in kitchen drawer knives were observed in a locked drawer. Cleaning supplies and dish soaps are stored in a locked cupboard under the kitchen sink sufficient perishable for a minimum of 2 days and non-perishable foods for a minimum of 7 days were observed. Medications are stored in a locked cupboard in the kitchen Bedroom #1, designated for bedridden use, was observed with 2 hospital beds, 2 night stands, 2 lamps, 2 chairs, 1 dresser, a closet. One of the hospital beds did not have a mattress and was not made up. Per information provided, the mattress was thrown out and needs to be replaced. The auditory device on the outside exiting door was barely audible and batteries were replaced to make them operational. Located inside the room is a private bathroom that is equipped with a walk in shower with

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

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: BELLAIRE SENIOR CARE	FACILITY NUMBER: 195850501
	VISIT DATE: 07/16/2024

NARRATIVE

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grab bars, non-skid mats, a single sink and a covered trash can. Water temperature tested read 119.3 degrees Fahrenheit. Resident equipment were stored in the private bathroom and need to be removed.
Bedroom #2 was observed with 2 hospital beds with bed rails placed along the center of the bed. The resident in the left bed is on hospice and the other is not. Also observed were 2 night stands, 2 lamps, 2 chairs and 4 little stands with small drawers that do not meet Title 22 requirements of 8 cubic feet for a dresser and a shared closet.
Bedroom #3 was observed with 2 hospital beds, 2 night stands, 2 chairs, 2 lamps and a shared closet. The mattress on the bed located to the left of the room was observed with a caved in mattress and needs to be replaced. Incontinence products for all the residents were stored in the closet and needs to be relocated.
The common bathroom was observed equipped with a shower, a toilet, a sink, grab bars and a non-skid mat. The water temperature was tested and read 120.6 degrees Fahrenheit.
The hardwired smoke detectors and combination smoke/carbon monoxide detectors located in the resident rooms, hallway and dining room were tested and were operational
the two fire extinguishers located in the kitchen were purchased on 1/11/24.
The auditory device on the front door and kitchen door were operational
the facility has central air and was in use during this visit
first aid kit contained the required scissors, tweezers and thermometer and first aid manual are stored in the kitchen
The facility has a land line and the telephone # is (323)284-8907
Resident and Family council posters, complaint poster, labor poster, personal rights poster were were observed.
The outside covered patio was observed with a table and 6 chairs.
The washer and dryer located in the outside patio was operational
The front and backyard were clean.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

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: BELLAIRE SENIOR CARE	FACILITY NUMBER: 195850501
	VISIT DATE: 07/16/2024

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The following deficiencies/actions need to be completed:

dressers meeting Title 22 requirements need to be purchased for bedroom #2 and #3
provide a mattress that is good condition for the beds located in bedroom #1 and bedroom #3.
adjust the water temperature slightly to ensure that the water temperature is within 105-120 degrees Fahrenheit.
Adjust the bed rail or remove the bed rail on the hospital bed located to the right side of bedroom #2. Ensure that a physician's order was obtained if the bed rail is retained.
Applicant will purchase liability insurance meeting Title 22 requirements upon licensure.

Applicant will make the noted corrections and provide evidence of the corrections.

Component III was conducted with Erna Gevorgyan , Administrator and David Abramyan, Staff.

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: 07/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

LIC809 (FAS) - (06/04)

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