197608066-3-8-2022-29-AS-EPEI-CCBV4Q-20220308150644

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608066
Report Date: 03/08/2022
Date Signed: 03/08/2022 03:09:30 PM

Document Has Been Signed on 03/08/2022 03:09 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:	FAMILY CARE MANOR		FACILITY NUMBER:	197608066
ADMINISTRATOR:	HASMIK SUKIASYAN		FACILITY TYPE:	740
ADDRESS:	14127 TIARA STREET		TELEPHONE:	(818) 988-4557
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91401
CAPACITY:	6	CENSUS: 2	DATE:	03/08/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Hasmik Sukiasyan, Administrator		TIME COMPLETED:	03:10 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	At 1:00 p.m., Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. LPA was greeted and screened by Administrator, Hasmik Sukiasyan. This annual had a specific emphasis on infection control practices and procedures. At 1:25 p.m., LPA, along with Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. KITCHEN: At 1:27 p.m., LPA observed the kitchen/dining area. Knives are stored in a locked cabinet. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 1:38 p.m., hot water measured at 105.4-degree Fahrenheit. Medications are located in a mobile locked storage cart stored in the kitchen. A Flashlight was observed near the kitchen area. COMMON AREAS: LPA observed common area to be relatively clean and properly furnished. LPA observed the fire extinguisher to be fully charged and purchased on 03/08/2022. Signs are posted throughout facility to promote handwashing, and cough/sneeze etiquette. At 1:20 p.m., fire alarms and carbon monoxide detectors were tested and functioning properly. BEDROOMS: LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. The sinks had sufficient liquid soap, and paper products. At 1:39 p.m., hot water measured at 112.8-degree Fahrenheit. A night light was present in the hallway. 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: 03/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022

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: FAMILY CARE MANOR	FACILITY NUMBER: 197608066
	VISIT DATE: 03/08/2022

NARRATIVE

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Continued from LIC 809.

OUTDOOR SPACE: At 1:34 p.m., LPA observed the front patio and back patio which has a covered outdoor area for resident use. There is a side gate designated for an emergency exit. Passageways were free and clear from obstruction.

GARAGE: The garage is attached to the house and remains locked and inaccessible to residents. First aid kit was located inside the garage. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in the garage. The laundry units are located inside the garage.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station.
LPA observed a 30-day supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate.
Between 1:10 p.m. - 1:30 p.m., LPA conducted Infection Control mitigation module with Administrator.

No deficiencies were observed at this time. Exit interview conducted. Report issued and a copy of the report will be provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022

LIC809 (FAS) - (06/04)

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