197606694-8-19-2024-31-AS-PKHN-D8AT8T-20240819143052

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606694
Report Date: 08/19/2024
Date Signed: 08/19/2024 02:32:47 PM

Document Has Been Signed on 08/19/2024 02:32 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	DAISY ANNE GARDENS		FACILITY NUMBER:	197606694
ADMINISTRATOR:	ESTELA MONDERIN		FACILITY TYPE:	740
ADDRESS:	20634 KITTRIDGE STREET		TELEPHONE:	(818) 704-4338
CITY:	WINNETKA	STATE: CA	ZIP CODE:	91306
CAPACITY:	5	CENSUS: 5	DATE:	08/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Estela Monderin-Administrator		TIME COMPLETED:	03:00 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	An unannounced annual visit was conducted by Licensing Program Analyst (LPA) Perchui Milena Khurshudyan on 8/19/24 at 9:45 am. Upon arrival LPA met with Estela Monderin the facility Administrator, who granted access to the facility. LPA explained the reason for the visit. Shortly after the Co-Administrator , Tajdari Daisy Shirin arrived and helped with physical plant tour and staff/residents files. During today's visit, LPA conducted a physical plant walk through, at approximately 10:20am, to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22. The following was observed: Facility is licensed for capacity of five (5) residents, of which five (5) may be Non-Ambulatory. Facility also has a hospice waiver for five (5) residents. There are four (4) bedrooms designated for residents’ use. Bedrooms are appropriately furnished and have appropriate lighting. There are two (2) bathrooms in the facility. LPA observed bathrooms have soap, paper towels and hand washing signs. The hot water temperature measured at 10:45 to be 106°F. Extra towels and linens were readily available. There are grab bars for each toilet and shower, bathrooms have non-skid mats. All trash cans in bathrooms had fitted lids to protect from cross contamination. The facility has alarms on all exit doors. Centrally stored medications are locked in the cabinets located in the hallway area. PRN medications have written orders from a physician. The facility serves residents with dementia. Potentially dangerous items are kept inaccessible to residents with dementia. There is staff to meet the needs of residents with dementia. Facility has 2 staff for AM shift and 1 awake caregiver for PM shift. Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui Khurshudyan	TELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024

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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: DAISY ANNE GARDENS	FACILITY NUMBER: 197606694
	VISIT DATE: 08/19/2024

NARRATIVE

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LPA observed the kitchen area, there was sufficient stock of one-week non-perishable foods and two days of perishable foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. LPA observed that sharp objects were stored in a locked drawer inaccessible to residents in care. The kitchen has a working gas stove, microwave, refrigerator, and freezer. Extra emergency food was properly stored inside the storage cabinet.

The common areas which include dining and living room appeared clean and were properly furnished. Temperature was comfortable it was measured at 11:00am to be 74°F. The fireplace was closed and non-operational. No obstructions and or tripping hazards throughout the facility found.

The Facility has three (3) fire extinguishers, LPA observed they are last purchased on 07/18/2024. Laundry room is located outside in the separate area. LPA observed all chemicals and detergents are kept locked and
inaccessible to residents in care inside the locked cabinets next to the laundry area. Smoke detectors and carbon monoxide monitors were tested at 11:15am and observed to be functional. LPA observed a clean covered patio and backyard furniture to accommodate the five (5) residents. Exit areas are free of obstructions and hazards. LPA checked inside of the locked shed it was used for facility maintenance purposes. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents. The facility does not have a swimming pool or body of water. There is no garage.

Between 11:30am to 1:30pm, LPA reviewed records and files of five (5) residents and three (3) staff/caregivers. A review of staff and resident records appeared to be complete. Resident’s files contain a signed admission agreements and a medical assessment, and all other required documentarians. A review of staff records indicates that all facility staff and who required caregiver background checks have received criminal record clearances, LPA reviewed LIC501s, LIC503s, LIC9052s, and Training and Education certificates. There are no residents with prohibited conditions residing at the facility.

Continue on LIC809C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui Khurshudyan	TELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024

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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: DAISY ANNE GARDENS	FACILITY NUMBER: 197606694
	VISIT DATE: 08/19/2024

NARRATIVE

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SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui Khurshudyan	TELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024

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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: DAISY ANNE GARDENS	FACILITY NUMBER: 197606694
	VISIT DATE: 08/19/2024

NARRATIVE

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At approximately 1:35pm to 2:00pm LPA observed each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the clients’ doctor. Proper medication dispensing instruction are followed and checked for contamination. All medications are properly labeled and checked for expiration dates.

First-aid has all proper items and is current.

LPA collected LIC500, LIC9020, Copy of the Administrator certificate, The Infection Control.

Facility is in compliance with Title 22 Regulations at this time. No citations issued during this visit.

Exit interview conducted and copy of this report signed and delivered to the Administrator.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui Khurshudyan	TELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024

LIC809 (FAS) - (06/04)

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