197608534-2-8-2023-29-AS-ECAS-CNUUVE-20230208145500

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608534
Report Date: 02/08/2023
Date Signed: 02/08/2023 02:55:33 PM

Document Has Been Signed on 02/08/2023 02:55 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ASSISTED COMFORT HOME		FACILITY NUMBER:	197608534
ADMINISTRATOR:	MARIAM KEVLIYAN		FACILITY TYPE:	740
ADDRESS:	23731 KILLION STREET		TELEPHONE:	(818) 800-9970
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 6	DATE:	02/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Mariam Kevliyan-Administrator		TIME COMPLETED:	03:00 PM

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Licensing Program Analyst (LPA) Elsie Campos 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 was greeted and scanned at the door by staff, Lilit Grigorian. The Administrator, Mariam Kevliyan arrived shortly after and was explained the reason for the visit.

The LPA toured the physical plant areas inside and outside, with staff at 1:35 p.m., to ensure there are no health and safety hazards.

KITCHEN: The LPA observed the kitchen/dining area to be clean and kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The LPA observed the kitchen refrigerator to be fully stocked at the time of visit. Knives and sharps are locked in a drawer at the kitchen island. Hot water temperature measured at 114.0 degrees Fahrenheit at 2:17 p.m.

BEDROOMS: There are (4) four bedrooms designated for resident use and (1) one bedroom designated for staff use. Staff bedroom is located adjacent to the kitchen. Bedroom #3 and Bedroom #4 have a direct exit to the exterior. The facility has furnished each room with clean linens, appropriate furnishings, and sufficient lighting for resident use.

RESTROOMS: Resident bathrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap and paper products. The LPA observed signs in all bathrooms promoting good hand hygiene. Bathroom hot water measured between 112.4 and 116.6 degrees Fahrenheit between 1:58 p.m. and 2:02 p.m.

Continued on LIC 809-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ASSISTED COMFORT HOME	FACILITY NUMBER: 197608534
	VISIT DATE: 02/08/2023

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COMMON SPACES: The LPA observed the living room area which is clean and properly furnished with seating, and a television for resident use. The LPA observed three (3) residents in the living room watching television during time of visit. Smoke detectors and Carbon Monoxide detectors are hardwired and interconnected. The LPA tested the fire alarm system at 2:15 p.m. and observed the system to be operating at the time of the visit. The LPA observed the fire extinguisher to be last serviced on 3/23/2022. Flooring was checked for cleanliness, all areas were clean, sanitary and in good repair. The LPA observed cameras in all common spaces and a screened fireplace in the living room. Medications were observed in a locked filing cabinet in the office area adjacent to the kitchen.

GARAGE AND GROUNDS: The facility does not have a garage. Locked cleaning supplies, emergency food supplies and additional incontinent supplies were observed in the laundry room adjacent to the kitchen. The LPA observed a covered patio area with patio furniture including a table and chairs for resident use. Facility has one (1) fence gate that self-latches with clear passageways for emergency exit use. There were no bodies of water accessible to residents at the time of visit.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. The LPA observed appropriate signage which promoted good hand hygiene, physical distancing, symptoms of COVID-19. The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE). Staff were observed wearing face coverings. All staff are fully vaccinated. No identified staffing concerns. The facility is in compliance regarding the requirements for indoor and outdoor visitation.

Exit interview conducted. No citations issued. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

LIC809 (FAS) - (06/04)

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