197608312-9-24-2023-31-AS-DESA-CVYQ4A-20230924115001

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608312
Report Date: 09/24/2023
Date Signed: 09/24/2023 11:50:05 AM

Document Has Been Signed on 09/24/2023 11:50 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME:	ADL BEST CARE LLC		FACILITY NUMBER:	197608312
ADMINISTRATOR:	ANNA VARDANYAN		FACILITY TYPE:	740
ADDRESS:	5433 MONROE STREET		TELEPHONE:	(323) 461-5602
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90038
CAPACITY:	5	CENSUS: 5	DATE:	09/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:10 AM
MET WITH:	Administrator, Anna Vardanyan		TIME COMPLETED:	11:50 AM

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	On 09/24/2023 at 8:00 am Licensing Program Analyst (LPA) David España conducted an unannounced 1-year Annual visit to the facility. Upon arriving at the facility, LPA met with staff shortly after the Administrator Anna Vardanyan, who assisted with the visit. The purpose of today’s visit was discussed. Upon arrival at the facility, LPA conducted a risk assessment at the front door (No COVID-19 cases). The facility has an approved mitigation plan on file. LPA toured the physical plant and observed the following: The facility has three (3) bedrooms and two (2) bathrooms currently occupying five (5) residents. The facility has one main entrance being used, there are required Covid-19 prevention signage (handwashing, coughing etiquette, and physical distancing) posted. The facility maintains a comfortable temperature at 70-degree Fahrenheit. The facility has a fire clearance for four (4) non-ambulatory, of which 1 may be bedridden in room #1, hospice waiver for 5. The facility has auditory alarms on all exits. LPA toured the kitchen and observed it be clean and an adequate supply of 2-day perishable and 7-day of non-perishable food located in the refrigerator, freezer, and kitchen cabinet. Food was properly labeled and stored. The pantry holds dishes. The facility has (4) refrigerators located in the detached garage and administrators business office behind the facility. The emergency food is stored and observed to be locked in the detached garage. Sharps were observed to be stored and locked in a kitchen top drawer adjacent to the kitchen sink. Fire extinguisher observed to be hanging on the wall in the dining room near the hallway, to have a purchase tag attached from Costco dated 04/20/2023. LPA observed no toxins, or anything being stored underneath the kitchen. A kitchen cabinet labeled “safety supply” to be locked and storing extra batteries, the Administrators ice cream money, personal care items and paperwork. LPA observed the locked medication cabinet adjacent to the kitchen sink, the facility (2) first aid kits and manual located and stored in the medication cabinet. LPA observed all bedrooms to be appropriately furnished with sufficient lighting. LPA observed appropriately bed linen and comforters on all beds. One (1) out of three (3) bedrooms are single occupancy. All bedrooms observed to be clean and clear from obstruction.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: ADL BEST CARE LLC	FACILITY NUMBER: 197608312
	VISIT DATE: 09/24/2023

NARRATIVE

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LPA observed (2) bathrooms to be clean and in proper operation. (1) out of (2) bathrooms are labeled for employees only and are inaccessible to residents. LPA observed the appropriate grab bars in and around the toilet and shower also non-skid mats located in the shower area. The hot water temperature range between 105F-120F degrees Fahrenheit. Hand towels are not shared. Bathrooms stocked and equipped with soap and paper towels. LPA observed the employee bathroom to have a locked cupboard storing cleaning supplies, incontinent supplies, and personal care items. Extra towels and linens are stored on a shelving unit above the toilet. LPA observed to be appropriately furnished with tables and chairs and adequate lighting. Observed to be neat and clean. Activities are stored in a cupboard in the dining room. File cabinets located in the dining room storing resident and staff files, clear from obstruction. LPA observed the fire alarm system was tested and observed to be working, it is hard wired and interconnected throughout facility. The facility has dual smoke/carbon monoxide detector located throughout the facility.

LPA observed the laundry room, which is located outside near the ramp in the back of the facility in a locked rubber shed labeled “Laundry”, to be clean and clear from obstruction and storing laundry supplies. LPA observed the detached garage to be locked and inaccessible to residents. The garage was clean, which had six (6) four (4) tier and (1) (3) tier shelving units storing the facilities extra non-perishable food, can goods, dry cereals, snacks, emergency food, personal care items, incontinent supplies, paper towels, tissue, cleaning products, water, and PPE. It is equipped with a refrigerator storing, meats, vegetables, and fruit. Extra linen, towels, comforter are stored in the garage. LPA observed a table and owning for seating, chairs, and extra table for lounging underneath a tarp providing a shaded area. Surrounding the facility was clean and clear from obstruction. It is also a space behind the facility being used as an office, it is equipped with a computer, printer, files etc. It also has a refrigerator storing bread, meats, and fruits. The facility has a rock fountain enclosed in a 3ft gate not being used, no bodies of water are located on the premises. LPA observed a small room located behind the rock fountain to be storing constructions supplies, tools, and storage bins. LPA observed one (1) Technical Assistance: Disaster Preparedness - Technical Assistance: 1569.695(a)(5)

No deficiencies cited. Exit interview conducted and a copy of this report was given at the time of visit to Anna Vardanyan, Administrator.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2023

LIC809 (FAS) - (06/04)

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