197608550-4-5-2022-29-AS-BBAI-CD7Q34-20220405114808

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608550
Report Date: 04/05/2022
Date Signed: 04/05/2022 11:50:59 AM

Document Has Been Signed on 04/05/2022 11:50 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:	QUEEN COMFORT CARE CENTER, INC.		FACILITY NUMBER:	197608550
ADMINISTRATOR:	GOHAR AMBARTSUMYAN		FACILITY TYPE:	740
ADDRESS:	6534 MCLENNAN AVENUE		TELEPHONE:	(818) 469-2995
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91406
CAPACITY:	6	CENSUS: 5	DATE:	04/05/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Nino Gelashvili - Licensee		TIME COMPLETED:	12:00 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	Licensing Program Analyst (LPA) Brian Balisi arrived to this facility today to conduct a One (1) year Required inspection of this facility with emphasis on infection control practices and procedures. LPA met with Licensee Nino Gelashvili and Administrator Gohar Ambartsumyan and explained the reason for the visit. At approx 09:15am, LPA toured the facility with Licensee and Administrator. Kitchen was observed to be inaccessible to residents at this time. The kitchen appeared to be clean at this time and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects were observed stored in the top drawer to the right of the stove. LPA observed drawer to be locked at this time. Cleaning supplies were observed to be kept locked under the sink. Laundry area was located next to the kitchen. LPA observed cabinets above washer and dryer to store PPE supplies. Cabinet to the right of the washer stored additional cleaning supplies and laundry detergent. LPA observed cabinet to be locked at this time. Dining room furniture appeared to be relatively clean and functional at this time. At 9:30am, LPA observed Resident 1 (R1), residing in room #4. LPA observed Room #4 notated as a staff room per LIC 999 facility sketch. Licensee was advised to relocate resident to a room that has approved fire clearance for resident use. The resident bedrooms were properly furnished with a bed, 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. LPA observed a sufficient supply of linen and personal hygiene supplies in the hallway closet nearest to the hallway bathroom. LPA observed all bathrooms were clean, properly supplied and had functional fixtures. The hot water was measured in each bathroom between 112 - 117 degrees Fahrenheit at this time.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

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: QUEEN COMFORT CARE CENTER, INC.	FACILITY NUMBER: 197608550
	VISIT DATE: 04/05/2022

NARRATIVE

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Continued from 809-C

Common Areas: These included the living room and dining room. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Dining room furniture appeared to be relatively clean and functional at this time. Medications were observed stored in the locked cabinet located in the laundry area. Client files were observed locked in cabinets in this area as well. LPA observed first aid kit properly supplied in the kitchen. Fire extinguisher were observed to be fully charged and purchased in September of 2021.

Outdoor Area: There was a shaded area with sufficient room for activities. LPA observed sufficient furniture designated for outdoor use. There are no bodies of water on the premises. LPA observed a sufficient amount of space for activities.There was a detached garage located on site. LPA observed garage to store extra furniture and medical supplies at this time. LPA did not observe any obstructions to emergency exits at this time.

The LPA spoke with Licensee and Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has 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 sufficient. If needed, the facility has the capacity to designate room #2 as a single isolation room if the facility has a confirmed case of COVID-19. COVID-19 testing is conducted weekly if there are any covid-19 concerns. The facility’s policies and procedures as it pertains to infection control are adequate at this time.

A $500 immediate civil penalty is assessed today. The Administrator and Licensee was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f).

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 809-D)
Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/05/2022 11:50 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: QUEEN COMFORT CARE CENTER, INC.	FACILITY NUMBER: 197608550
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation and record review, the licensee did not comply with the section cited above, as Resident 1 (R1) residing in Room #4, that does not have fire clearance, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/06/2022
	Plan of Correction
1 2 3 4	Within 24 hours, the licensee agreed to relocate R1 to a room that has fire clearance. Licensee will also submit a STD850 and facility sketch for the fire department to complete a new assessment. This is a zero tolerance violation, resulting in a civil penalty in the amount of $500.

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

LIC809 (FAS) - (06/04)

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