197608568-3-16-2022-31-AS-LQLY-CCKSRJ-20220316140625

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608568
Report Date: 03/16/2022
Date Signed: 03/16/2022 02:07:22 PM

Document Has Been Signed on 03/16/2022 02:07 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ADL BEST CARE 2		FACILITY NUMBER:	197608568
ADMINISTRATOR:	ANNA VARDANYAN		FACILITY TYPE:	740
ADDRESS:	5431 MONROE STREET		TELEPHONE:	(323) 461-5602
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90038
CAPACITY:	5	CENSUS: 4	DATE:	03/16/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Anna Vardanyan		TIME COMPLETED:	02:07 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) LaQueena Lacy arrived to the facility at 10:55am on 03/16/2022. LPA met with administrator Anna Vardanyan and explained the purpose of the visit, for a required One (1) Year Annual visit. A tour of the physical plant was conducted at 11:00am and the following was observed: The facility has one main entrance being used, there are required Covid-19 prevention signage (hand washing, coughing etiquette, and physical distancing) posted. The PPE screening station is located on the front porch on a table near the entrance equipped with sufficient PPE readily accessible, a standing free hand thermometer, hand sanitizer, gloves, mask, and sign in sheet at the time of visit. The facility maintains a comfortable temperature at 74 degree Fahrenheit. The facility has Three (3) bedrooms and two (2) bathrooms. Bedrooms: At 11:02am LPA observed all bedrooms to be appropriately furnished with sufficient lighting. One (1) out of (3) bedrooms are vacant. Two (2) of the bedrooms are shared occupancy. All bedrooms observed to be clean and clear from obstruction. Kitchen: At 11:11am the kitchen was observed to be clean and an adequate supply of perishables and non-perishable food located in the refrigerator, freezer, and kitchen cabinet. Food was properly labeled and stored. The facility has (1) refrigerators located in the detached garage behind the facility. (1) located uin the office. The emergency food is stored and observed to be locked in the detached garage. Sharps were observed to be stored and locked in a kitchen top drawer adjacent to the kitchen sink below the microwave. (Continued on LIC809C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ADL BEST CARE 2	FACILITY NUMBER: 197608568
	VISIT DATE: 03/16/2022

NARRATIVE

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Fire extinguisher observed to be hanging on the wall near the dining room and hallway, to have a purchase tag attached from Home Depot dated 05/20/2021. LPA observed toxins, cleaning solutions, and soaps locked and stored underneath the kitchen sink.

Medications: LPA observed the locked medication cabinet at 11:18am adjacent to the kitchen sink above the microwave. The facility has (2) first aid kits and manual located and stored in the medication cabinet.
(Continued on LIC 809C)

Bathroom: At 11:25am LPA observed (2) bathrooms to be clean and in proper operation. LPA observed the appropriate grab bars in and around the toilet and shower also non-skid mats located in the shower area. The water temperature range between 108.6 – 108.8 degrees Fahrenheit. Hand towels are not
shared. Bathrooms stocked and equipped with soap and paper towels.

Living, dining room and common areas: At 11:34am LPA observed to be appropriately furnished with tables
and chairs and adequate lighting. Observed to be neat and clean. Activities are stored in a cupboard in the dining room. File cabinets located in the dining room storing resident and staff files, clear from obstruction.

Laundry Room: At 11:39am LPA observed the laundry room, which is located outside near the ramp in the back of the facility in a locked rubber shed labeled “Laundry”, to be clean and clear from obstruction and storing laundry supplies.

Garage: At 11:43am LPA observed the detached garage to be locked and inaccessible to residents. The garage was clean, which had six (6) four (4) tier and (1) (3) tier shelving units storing the facilities extra non-perishable food, can goods, dry cereals, snacks, emergency food, personal care items, incontinent supplies, paper towels, tissue, cleaning products, water and PPE. It is equipped with a refrigerator storing meats, vegetables and fruit. Extra linen, towels, comforter are stored in the garage.
(Continued on LIC809C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ADL BEST CARE 2	FACILITY NUMBER: 197608568
	VISIT DATE: 03/16/2022

NARRATIVE

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Backyard: At 11:51am LPA observed a table and owning for seating, chairs and extra table for lounging underneath a tarp providing a shaded area. Surrounding the facility was clean and clear from obstruction. It is also a space behind the facility being used as an office, it is equipped with a computer, printer, files etc. It also has a refrigerator storing bread, meats, and fruits. The facility has a rock fountain enclosed in a 3ft gate not being used, no bodies of water are located on the premises. LPA observed a small room located behind the rock fountain to be storing constructions supplies, tools, and storage bins.

At 11:57am the fire alarm system was tested and observed to be working, it is hard wired and interconnected throughout facility. The facility has dual smoke/carbon monoxide detector located throughout the facility.

Exit interview conducted. Copy of this report issued

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022

LIC809 (FAS) - (06/04)

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