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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608066
Report Date: 02/03/2023
Date Signed: 02/03/2023 12:41:31 PM


Document Has Been Signed on 02/03/2023 12:41 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 MANORFACILITY NUMBER:
197608066
ADMINISTRATOR:HASMIK SUKIASYANFACILITY TYPE:
740
ADDRESS:14127 TIARA STREETTELEPHONE:
(818) 988-4557
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91401
CAPACITY:6CENSUS: 2DATE:
02/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Hasmik Sukiasyan, Administrator TIME COMPLETED:
12:55 PM
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced required annual visit. At 11:30 a.m., the LPA met with staff and explained the reason for the visit. At 11:42 a.m., the Administrator arrived at the facility. This annual had a specific emphasis on infection control practices and procedures.

At 11:56 a.m., the LPA along with the 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: Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 12:07 p.m., hot water measured at 112.4-degree F. Medications are located in a locked mobile storage cart stored in the kitchen. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. RESTROOMS: Restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. At 11:59 a.m., the hot water temperature tested at 113.1-degree F. OUTDOOR SPACE: At 10:01 a.m., the LPA observed the back patio which has a covered outdoor area for resident use. COMMON SPACES: At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the fire extinguishers to be fully charged and last purchased on 03/08/2022. Signs are posted throughout facility to promote handwashing. At 12:09 p.m., smoke alarms/ carbon monoxide detectors were tested and functioning properly. The LPA observed cameras in the common areas. The fireplace is appropriately screened. GARAGE: The garage is attached to the house and remains inaccessible to the residents. The laundry units are located inside the garage. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away inside the locked garage. INFECTION CONTROL: The LPA observed a 30-day supply of Personal Protection Equipment (PPE). The facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies were observed at this time. Exit interview conducted. A copy of the report was provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2023
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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