197608312-6-6-2025-31-AS-RCOR-DHDSRH-20250606140623

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608312
Report Date: 06/06/2025
Date Signed: 06/06/2025 02:08:03 PM

Document Has Been Signed on 06/06/2025 02:08 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:	ADL BEST CARE LLC		FACILITY NUMBER:	197608312
ADMINISTRATOR/ DIRECTOR:	ANNA VARDANYAN		FACILITY TYPE:	740
ADDRESS:	5433 MONROE STREET		TELEPHONE:	(323) 461-5602
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90038
CAPACITY: 5	TOTAL ENROLLED CHILDREN: 0	CENSUS: 3	DATE:	06/06/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:35 AM
MET WITH:	Anna Vardanyan		TIME VISIT/ INSPECTION COMPLETED:	02:00 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 Friday, 06/06/25, 8:35 am, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct an unannounced annual inspection visit. LPA met with Administrator, Anna Vardanyan, and reason for the visit was discussed. Facility is licensed as a single-story residence. Fire clearance approved for four (4) non-ambulatory and one (1) bedridden resident in bedroom#1. Hospice waiver approved for five (5) residents. Facility has three (3) resident bedrooms; One (1) private bedroom and two (2) shared bedrooms. At 08:50 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. All facility exits signal an auditory alert when accessed. Screening area is located immediately upon entrance. Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Hand washing, coughing etiquette, and other necessary signage are posted throughout the facility. Room temperature is comfortable; wall thermostat displays a setting of 73.0°F. within the required range. Side door is located west of house, exiting to back yard. The facility maintains an approved Mitigation and Infection Control plan. Required facility postings are prominently displayed and observed to be current. Disaster drills were last conducted on 06/01/25. FIRE DETECTION SYSTEM: Present in the facility. Multiple smoke alarms are installed, hardwired, and interconnected. Smoke and Carbon monoxide detectors were tested and function properly. LPA observed one fire extinguisher, located on dining room wall near the hallway. Purchase/Service Date: 03/07/2025. [LIC 809C-Continued]

Eva Miller	TELEPHONE: (818) -596-4373
Raymond Comer	TELEPHONE: 818-401-8655
	DATE: 06/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: ADL BEST CARE LLC	FACILITY NUMBER: 197608312
	VISIT DATE: 06/06/2025

NARRATIVE

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KITCHEN: LPA observed kitchen as clean and clear of obstruction. Kitchen is equipped with a functional stove, refrigerator, multiple appliances, with adequate supply of perishable and non-perishable food. Foods 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. First Aid kit is complete, with manual, and stored in the medication cabinet.

BEDROOMS: All Bedrooms are observed as clean, with sufficient lighting, and properly furnished with bed, linens, chair, chest of drawers, and night stand.

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 113°F. Within the required range. Wash cloths and towels are not shared.

LAUNDRY: Washer and Dryer machines, soaps, and other cleaning agents, are stored in a large outdoor shed observed as locked and inaccessible to residents. Linen storage observed to have adequate supply of linen and towels.

COMMON AREAS: Entry and exit doors have a functional auditory alert when accessed. Dining room is furnished with table large enough to accommodate residents. Sitting area, television, stored games, reading materials are present and available. Furniture and fixtures are clean and good condition. Facility telephone was operational at time of visit.

OUTDOORS: (backyard) area observed having a shaded patio, table, and sufficient seating for the residents. Furnishings observed to be in good condition. A room behind the facility is an office space. Office contains an additional refrigerator which stores resident foods properly stored and labeled. Office observed to be locked and inaccessible to residents. 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. All trash cans were observed as covered.

[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: 06/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025

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: ADL BEST CARE LLC	FACILITY NUMBER: 197608312
	VISIT DATE: 06/06/2025

NARRATIVE

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RESIDENT RECORDS: are located in the office area; stored in locked cabinets and inaccessible to residents. Records were reviewed for current IPP and/or Needs and Services plans, physician report, appraisals, and admission agreements, and other required documentation. Resident records appear to be complete and current.

STAFF RECORDS: are located in the office areas: stored in locked cabinets and inaccessible to residents. Records were checked for criminal record clearances\associations to this facility and other required documentation. 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: 06/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025

LIC809 (FAS) - (06/04)

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