197608410-1-14-2025-29-AS-TBYE-DCWULR-20250114144111

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608410
Report Date: 01/14/2025
Date Signed: 01/14/2025 02:41:29 PM

Document Has Been Signed on 01/14/2025 02:41 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	LAURELGROVE MANOR		FACILITY NUMBER:	197608410
ADMINISTRATOR/ DIRECTOR:	SELVA W BANOS		FACILITY TYPE:	735
ADDRESS:	7841 LAURELGROVE AVENUE		TELEPHONE:	(818) 255-4733
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY: 4		CENSUS: 4	DATE:	01/14/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:31 AM
MET WITH:	Selva Banos		TIME VISIT/ INSPECTION COMPLETED:	02:45 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) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 10:31 AM. LPA met with facility staff who contacted the facility Administrator Selva Banosvia telephone call. The Administrator arrived to the facility at approximately 10:50 AM Entrance interview conducted and the reason for the visit was explained.

Beginning at 10:35 AM, the LPA, along with the Administrator and facility staff member Hasmik Hakhinyan (S1) toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

OUTDOOR SPACE: The facility has one (1) emergency exit gate located on the back side of the facility LPA observed clear passageways for emergency exit use. The facility has adequate shaded outdoor seating for resident use. LPA observed an appropriately secured laundry closet to contain a washer and dryer along with laundry chemicals. There is an additional building on the property that is not associated with the facility. LPA observed cameras throughout the outdoor areas of the facility.

BATHROOMS: There are two (2) bathrooms at the facility. Both are designated as common resident bathrooms. All bathrooms were observed to be clean and in good repair and were equipped with nonskid surfaces. The water temperature was measured in both bathrooms between 110.7 degrees Fahrenheit and 111.2 degrees Fahrenheit which is in compliance with regulation. Bathroom #2 was observed to contain a locked under sink cabinet that contained cleaning chemicals and supplies.

Continued on LIC 809C.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

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 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LAURELGROVE MANOR	FACILITY NUMBER: 197608410
	VISIT DATE: 01/14/2025

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

BEDROOMS: There are four (4) bedrooms in the facility; three (3) are designated for resident use and one (1) is designated as a staff room. Two (2) resident bedrooms are private rooms, and one (1) resident bedroom is a shared room. LPA toured all four (4) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, emergency flashlights, and sufficient lighting. The staff room was observed to be locked and inaccessible to clients in care.

KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. The LPA observed a fire extinguisher to be fully charged and serviced on 10/31/2024.

COMMON AREAS: This includes the living room, dining room, and hallway. LPA observed the living room to be clean and properly furnished at the time of the visit. LPA observed the living room to contain couches and activities for resident use. The dining room was observed to be clean and contains adequate seating for resident use. The hallway was observed to contain two (2) properly secured closets. One (1) secured closet contained resident files and medications along with tools for facility maintenance. One (1) secured closet contained cleaning supplies, emergency food and water supplies, knives and other sharp utensils, and additional care supplies. Smoke detectors and carbon monoxide detectors were tested at 12:21 PM and were functional at the time of the visit.

RECORD REVIEW: Record review began at 11:20 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Six (6) staff files were reviewed. All staff files contained the required documents and trainings. Four (4) resident files were reviewed. All resident files contained all required documentation and signatures. No deficiencies were observed during record review.

Continued on LIC 809C.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LAURELGROVE MANOR	FACILITY NUMBER: 197608410
	VISIT DATE: 01/14/2025

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

MEDICATION REVIEW / CASH RESOURCE REVIEW: Cash resource review began at 12:10 PM. Cash resources were reviewed for four (4) of four (4) residents. All cash resources reviewed were documented and stored appropriately with corresponding receipts. No deficiencies were observed during cash resource review. Medication review began at 12:15 PM. Medications are stored centrally and securely in a locked closet in the hallway. Medications for three (3) residents were observed. All medications reviewed were documented properly on their centrally stored medication and destruction record sheet. No deficiencies were observed during medication review.

INFECTION CONTROL / EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the
facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Last emergency disaster drill was conducted 12/14/2024. The facility’s emergency disaster plan and infection control plan are reviewed/updated by the facility administrator annually.

INTERVIEWS: LPA interviewed two (2) residents one (1) staff member. One (1) resident interview revealed concerns with the volume of S1’s voice while speaking in Armenian. No other resident concerns were noted during the interviews. LPA interviewed S1 with the assistance of the Administrator acting as a translator. S1 was knowledgeable on their role and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse. S1 informed LPA that they do not yell at the residents in Armenian. S1 stated that they naturally speak loudly and only communicate with the residents in English. If translator services are required while communicating S1 utilizes the Google translate app. S1 stated that they will control their speaking volume around the residents in the future to avoid further concerns.

During today’s visit LPA obtained a copy of the facility’s updated LIC500, surety bond, and liability insurance.

No deficiencies were observed during today’s inspection. The Administrator was unavailable to sign this report but has designated S1 to sign on their behalf. The report was read to the Administrator via telephone call. Exit interview conducted and copy of the report was issued.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

LIC809 (FAS) - (06/04)

Page: 4 of 4