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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608550
Report Date: 04/28/2023
Date Signed: 04/28/2023 02:57:25 PM


Document Has Been Signed on 04/28/2023 02:57 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:QUEEN COMFORT CARE CENTER, INC.FACILITY NUMBER:
197608550
ADMINISTRATOR:GOHAR AMBARTSUMYANFACILITY TYPE:
740
ADDRESS:6534 MCLENNAN AVENUETELEPHONE:
(818) 469-2995
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY:6CENSUS: 6DATE:
04/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Nino Gelashvili and Gohar AmbartsumyanTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at 9:00 a.m. The last annual conducted at this facility was on 04/05/2022. Upon arrival, the LPA was greeted by staff. The Licensee, Nino Gelashvili and Administrator, Gohar Ambartsumyan arrived shortly after and the reason for the visit was explained. Entranced interview conducted

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: The LPA began the inspection in the kitchen/food service area at 9:36 a.m. Knives are stored in a locked drawer next to the oven. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Cleaning supplies were observed under the kitchen sink locked and inaccessible to residents in care.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were tested at 9:46 a.m. and operational at the time of the visit. The fire extinguisher was fully charged and last serviced 11/16/2022. All exits have functioning auditory devices and were operational at the time of the visit. The LPA observed required postings throughout the common space. There is a separate laundry room, which is kept locked.

The backyard has a covered outdoor area equipped with furniture for resident use. The facility has one (1) side gate that self-latches with no obstructions in case of an emergency at this time. There were no bodies of water noted.

Report Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023
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: QUEEN COMFORT CARE CENTER, INC.
FACILITY NUMBER: 197608550
VISIT DATE: 04/28/2023
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Report Continued from LIC 809...

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There was a linen closet in the hallway with extra towels and linens.

RESTROOMS: The two resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. The hot water temperature was measured and in compliance at the time of the visit between 105- and 120-degrees Fahrenheit.

RECORDS: Records review of resident files began at 10:24 a.m.; six (6) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. All records were in order. The LPA reviewed three (3) personnel files for, but not limited to, the following: personnel records, health screening, criminal record statements, and current first aid certification. All files were complete. The LPA also audited the current Administrator’s file and it was in order.

MEDICATIONS: Medications review began at 12:00 p.m. The medications are centrally stored and locked in a cabinet next to the kitchen. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of COVID. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed.

During today’s visit, the LPA obtained the following documents: Personnel Report (LIC 500), Client Roster (LIC 9020), a copy of the Emergency Disaster Plan (LIC 610E), and a copy of current liability insurance.

No deficiencies cited at this time. Exit interview. A copy of the report was issued.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
LIC809 (FAS) - (06/04)
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