197608459-7-21-2022-29-AS-SWAR-CGJP58-20220721110020

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608459
Report Date: 07/21/2022
Date Signed: 07/21/2022 11:01:09 AM

Document Has Been Signed on 07/21/2022 11:01 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	EMVY BOARD AND CARE FACILITY		FACILITY NUMBER:	197608459
ADMINISTRATOR:	EMMA KOCHINYAN		FACILITY TYPE:	740
ADDRESS:	14164 COHASSET STREET		TELEPHONE:	(818) 947-1711
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY:	6	CENSUS: 5	DATE:	07/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Emma Kochinyan, Administrator		TIME COMPLETED:	11:00 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	Licensing Program Analyst (LPA) Salia Walker arrived at the facility unannounced to conduct a required annual visit. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Emma Kochinyan at 9:22 a.m., and explained the reason for the visit. The LPA toured the physical plant areas inside and outside, with Administrator Emma Kochinyan at 9:26 a.m., to ensure there are no health and safety hazards. BEDROOMS: The LPA observed the resident bedrooms which were furnished with clean linens, appropriate furnishings, and sufficient lighting. RESTROOMS: From 9:33 a.m. until 9:39 a.m., Resident restrooms were observed not clean, or sanitary around the sink areas. The LPA advised the Administrator the facility shall be clean, and sanitary at all times. Restrooms were observed in operating condition with grab bars and non-skid surfaces. The LPA advised the Administrators to ensure that bathrooms were stocked with paper towels and hand-washing signs. From 9:33 a.m. until 9:39 a.m., hot water temperatures measured between 105.5 and 109.5 degrees Fahrenheit in the common and private restroom(s). KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be properly stored and locked at time of visit. Hot water measured 112.5 degrees Fahrenheit at 9:28 a.m. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed required postings in the hallway. One (1) fire extinguisher was observed to be fully charged and purchased on 01/2022. Continue on LIC809C..

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-326-5838
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: EMVY BOARD AND CARE FACILITY	FACILITY NUMBER: 197608459
	VISIT DATE: 07/21/2022

NARRATIVE

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BACKYARD: There is one (1) additional refrigerator in the back yard containing food. There is one (1) shed in the backyard utilized as additional storage. The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. The garage is attached to the facility. The Laundry area is located in the facility garage, which contains additional cleaning supplies, and chemicals. The garage is also being utilized for additional storage.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE), and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is insufficient at this time, and the Administrator acknowledged. The Infection Control plan has not yet been submitted, and the Administrator will submit to CCL. This facility has records of staff and resident vaccinations. The facility can designate a single-person room to isolate persons if there is a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time and the LPA reviewed facility’s policies, and procedures as it pertains to infection control.

The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22. Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-326-5838
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 07/21/2022 11:01 AM - It Cannot Be Edited

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: EMVY BOARD AND CARE FACILITY	FACILITY NUMBER: 197608459
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation, the licensee did not comply with the section cited above as resident restrooms were observed not clean, or sanitary around the sink areas, which poses a potential health and safety risk to residents in care.
	POC Due Date: 07/25/2022
	Plan of Correction
1 2 3 4	The Licensee has agreed to do the following: 1.Submit photos of clean, and sanitary facility restrooms to CCL by 7/25/22.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-326-5838
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022

LIC809 (FAS) - (06/04)

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