197608599-12-8-2023-29-AS-BBAI-CYBU5L-20231208141654

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608599
Report Date: 12/08/2023
Date Signed: 12/08/2023 02:17:56 PM

Document Has Been Signed on 12/08/2023 02:17 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:	VALLEY'S BEST HOMECARE		FACILITY NUMBER:	197608599
ADMINISTRATOR:	GAMLET KUYUMCHYAN		FACILITY TYPE:	740
ADDRESS:	15029 GILMORE STREET		TELEPHONE:	(818) 778-0202
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91411
CAPACITY:	6	CENSUS: 5	DATE:	12/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Gamlet Kuyumchyan		TIME COMPLETED:	02:30 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 at the facility unannounced to conduct a required annual visit at 08:30am. Upon arrival LPA met with Staff and explained the reason for the visit. Shortly after Administrator Gamlet Kuyumchyan and explained the reason for the visit. At approximately 09:00am, tour of the physical plant was conducted with Administrator. Facility has (3) resident bedrooms and three (3) bathrooms LPA toured the facility with Stiles. The kitchen appeared to be relatively 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 container underneath the sink. LPA observed cabinet to be inaccessible to residents in care. There is a dedicated area for the posting of required documents located in the living room next the entry way. The common areas were observed to be properly furnished and relatively clean at the of the visit. At 9am, LPA observed a resident watching television. The living room was observed to be relatively clean during the visit. The facility maintains a comfortable temperature at 73°F. The smoke and dual carbon monoxide detectors were tested and observed to be operational. Fire extinguisher is located at kitchen and observed to be full and last serviced on May 2023. There is a small office space located in the living area. No health or safety concerns observed in this area during visit. LPA observed appropriate signage regarding infection control posted throughout the facility. LPA observed sanitizer readily available in areas with high touch surfaces. Dining room furniture appeared to be relatively clean and functional 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: 12/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

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: VALLEY'S BEST HOMECARE	FACILITY NUMBER: 197608599
	VISIT DATE: 12/08/2023

NARRATIVE

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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.

All bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. The hot water temperature measured between 105 and 120 degrees Fahrenheit.

The backyard of the facility has outdoor furniture and TV with a covered shaded area with sufficient room for activities. LPA did not observe any obstructions to emergency exits at this time. The swimming pool was appropriately fenced and observed to be locked and secured. There was a detached ADU observed next to the pool behind a locked fence. Tenants of the ADU allowed LPA to enter home, LPA did not observe any health or safety concerns at this time. LPA observed separate entrance that led to ADU.

The garage is attached to the home and observed to be locked and secured. The garage is currently being used as a laundry area, storage of non-perishable and frozen food, supplies and old/used equipment. Laundry detergents, cleaning solutions and other toxins were observed to be kept in a locked cabinet inside the garage near the laundry area.

Records review began at approx. 09:45am, five (5) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. four (4) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were observed to be in order at this time.

Medications review began at approximately 11 a.m. The medications are centrally stored in a locked medication cabinet cart in the dining area. LPA reviewed medications for five (5) residents. Medications are properly documented on the centrally stored medications and destruction record.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

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: VALLEY'S BEST HOMECARE	FACILITY NUMBER: 197608599
	VISIT DATE: 12/08/2023

NARRATIVE

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Between 1pm - 2pm , LPA interviewed five (5) residents and three (3) staff.

The LPA spoke with Gamlet 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 #3 as a single isolation room if the facility has a confirmed case of a communicable disease. COVID-19 testing is conducted weekly if there are any communicable disease concerns. The facility’s policies and procedures as it pertains to infection control are adequate at this time.

LPAs obtained the following documents - Census and staff schedule.

Exit interview conducted and report issued to Administrator.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

LIC809 (FAS) - (06/04)

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