197608349-1-12-2023-31-AS-TCAS-CMZU2Z-20230112141246

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608349
Report Date: 01/12/2023
Date Signed: 01/12/2023 02:15:21 PM

Document Has Been Signed on 01/12/2023 02:15 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ABBEY ROAD VILLA		FACILITY NUMBER:	197608349
ADMINISTRATOR:	MARINE KARAPETIAN		FACILITY TYPE:	740
ADDRESS:	14132 HUBBARD STREET		TELEPHONE:	(818) 837-0077
CITY:	SYLMAR	STATE: CA	ZIP CODE:	91342
CAPACITY:	78	CENSUS: 59	DATE:	01/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Marine Karapetian		TIME COMPLETED:	02:30 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	Licensing Program Analyst (LPA) Tuesday Cabiness met with Administrator Marine Karapetian for a One (1) Year Required - Infection Control visit for this facility. A physical plant inspection of common areas, bathroom, resident rooms, and kitchen were inspected. Before entering the facility, there is a main gate about 150 ft to get to the main door, that has to be opened by the Administration office or have the gate code to enter. There is only one entrance being utilized at the facility, the front main entrance door. There is sign-in sheets and cleaning station at the receptionist desk. The facility has COVID and hand-washing signs posted throughout the facility on the walls and resident doors. Staff and residents were observed to be wearing mask during visit. The facility has submitted the new infection control plan to LPA. There are hand sanitizing stations all over the facility. There are signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in common bathrooms and all over the common areas of the facility. The facility have designated visitors' area at the front yard. The facility has sufficient stock of PPE and COVID tests. The facility is a single story building with shared and private bedrooms and bathrooms. There are smoke and carbon monoxide detectors all over the facility. Fire extinguishers were observed are fully charged. All indoor and outdoor passageways/exits were free of obstruction.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ABBEY ROAD VILLA	FACILITY NUMBER: 197608349
	VISIT DATE: 01/12/2023

NARRATIVE

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Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient supply of perishable and non-perishable food and properly stored at the facility. Knives, cleaning agents, and other potentially hazardous items were locked and inaccessible.

Bedrooms: The resident bedrooms were properly furnished with one chair, night stand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Beds are 6 feet a part.

Bathrooms: LPA observed all bathrooms to be clean, properly supplied and equipped with functional fixtures. LPA observed grab bars and non-skid mats in all bathrooms. Residents have sufficient amounts of supplies for personal hygiene.

Common Areas: These includes the living room, dining room and outdoor areas. Facility common areas appeared to be clean and appropriately furnished at the time of this visit, no accessible hazards were observed.

Medications: Stored in designated medication room. LPA reviewed resident medication records and medication. No errors noted during visited.

Resident/Staff File Review: Resident's physician report and appraisal/needs & service plan were updated and current. Staff first aid and CPR certificates current. Training records were reviewed and facility has a Registered Nurse and an online training program for staff.

COVID Procedures/Protocols: All new hires and admits, facility requires vaccination before entering. Facility continues to weekly COVID test residents and staff. There are designated rooms for positive cases. During today's visit, Public Health were administering the new COVID booster shot (Vivalent) to residents.

Exit interview conducted. Copy of this report issued

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

LIC809 (FAS) - (06/04)

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