197608312-7-22-2024-31-AS-RCOR-D7EJTV-20240722072034

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608312
Report Date: 07/19/2024
Date Signed: 07/22/2024 07:21:44 AM

Document Has Been Signed on 07/22/2024 07:21 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

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:	07/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Anna Vardanyan		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

On 07/19/24, 10:00AM, Licensing Program Analyst (LPA) Raymond Comer conducted an unannounced Annual visit at the Facility. LPA met with Facility Administrator, Anna Vardanyan, and reason for the visit was stated. Administrator Certificate is Valid with expiration date: 4/10/2025

Facility is licensed as a single-story residence, fire clearance for four (4) non-ambulatory, and one (1) bedridden allowed in Room#1. Hospice Waiver Approved for five (5). Facility has three (3) resident bedrooms; two bedrooms are shared, and one (1) bedroom is private. There are two (2) bathrooms.

At 10:15 AM, LPA conducted a tour of the physical plant with the Administrator and observed the following:

Physical plant was inspected for cleanliness and condition. Facility’s main door is the primary entry/exit access and additional exit point is located in Facility’s rear area. Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Covid 19 prevention protocols are posted. Hand washing, coughing etiquette, and other necessary signage are posted in the bathroom and throughout the facility. Room temperature is comfortable; wall thermostat displays a setting of 74.0°F., within the required range.
The facility has submitted and approved Mitigation and Infection Plan. Required postings are prominently displayed and observed to be current. Disaster drills were last conducted on 6/1/2024.

Fire Detection system is present in the facility. Multiple smoke alarms are installed, hardwired, and interconnected; Carbon monoxide alarms are installed. Smoke and Carbon monoxide detectors were tested and function properly. LPA observed one fire extinguisher hanging on the wall in the dining room near the hallway. Purchase/Service Date: 04/06/2024.

[LIC 809C-Continued]

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond Comer	TELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

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: ADL BEST CARE LLC	FACILITY NUMBER: 197608312
	VISIT DATE: 07/19/2024

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
26
27
28
29
30
31
32

Kitchen: At 11:27 AM LPA observed kitchen as clean, equipped with a functional stove, Refrigerator, multiple appliances, with adequate supply of perishables and non-perishable foods. Foods were observed as properly labeled and stored. Kitchen cabinets store dishes, plastic, paper goods and utensils. Knives and sharps are secured in a locked drawer and inaccessible to residents.

Medications are stored in a secured medications cabinet near the Kitchen area and are inaccessible to residents. Medications are listed on a centrally stored medication and destruction record log. A First Aid kit is complete with Manual and stored in the medication cabinet.

Garage\Laundry: Garage is detached to the house and was observed to be locked. Garage is a storage for PPE, Emergency Food/Water, and various other supplies. Garage also contains a working Refrigerator with additional meats, juices, and produce for Facility use. Foods were properly stored and labeled.

Laundry: Facility Washer\Dryer Unit, Laundry soaps, and cleaning agents are stored in a large outdoor shed. LPA observed this shed as locked and inaccessible to Residents. Linen storage observed to have adequate supply of linen and towels.

Commons: LPA observed all common areas of the facility, including the resident dining area. LPA observed common areas to be clean, organized, properly furnished and in good condition. Furniture in common area was observed to be in good repair.

Bedrooms are observed as clean with sufficient lighting, properly furnished with bedding, linens, at least one chair, dresser, nightstand, and closet space.

Bathrooms were observed to be clean and sanitary, with necessary supplies and required safety fixtures (grab bars, anti-slip floor stripping). Hot water temperature measured at 106.5°F., Within the required range.

Outdoor: At 12:20 pm, (backyard) area observed to have a shaded patio, with table with sufficient seating for the residents. Outdoor furniture observed to be in good condition. A room behind the facility is an office space. Office is observed to be locked and inaccessible to residents. The facility has a rock fountain enclosed in a 3-ft. gate and observed as dry and not in use. There are no bodies of water in the facility.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond Comer	TELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: ADL BEST CARE LLC	FACILITY NUMBER: 197608312
	VISIT DATE: 07/19/2024

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
26
27
28
29
30
31
32

RESIDENT RECORDS are stored in secure and locked cabinets in office area and are inaccessible to residents. Records were reviewed for current IPP and/or Needs and Services plans, physician report, and admission agreements. Resident records appear to be complete and current.

STAFF RECORDS are stored in secure and locked cabinets in office area and are inaccessible to residents. Records were checked for criminal record clearances\associations to this facility. Staff records appear to be complete and current.

No immediate health and safety hazards observed during the day of inspection. Exit interview conducted and a copy of this report was given.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond Comer	TELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3