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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608678
Report Date: 03/14/2024
Date Signed: 03/14/2024 03:15:33 PM


Document Has Been Signed on 03/14/2024 03:15 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:HARTLAND CARE, INC.FACILITY NUMBER:
197608678
ADMINISTRATOR:ANI MAKARYANFACILITY TYPE:
740
ADDRESS:8224 ZELZAH AVENUETELEPHONE:
(818) 697-5363
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:6CENSUS: 3DATE:
03/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Dianna Makaryan, AdministratorTIME COMPLETED:
03:45 PM
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At 11:45 AM, Licensing Program Analyst (LPA) Huma Rahimi, conducted an unannounced annual visit. LPA met with Administrator, Dianna Makaryan and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out.

The facility is a single story building with four (4) bedrooms, two (2) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for six (6) nonambulatiory residents, of which one (1) may be bedridden in Bedroom # one (1). The facility serves residents with dementia. Approved hospice waivers for six (6). The facility uses surveillance cameras on the interior and exterior.

Kitchen: At approximately, 11:55 AM LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps observed to be locked in a kitchen cabinet. A fully charged fire extinguisher hung near the kitchen serviced on

Laundry Room: At 12:00 PM, LPA observed that the cleaning solutions were locked in the laundry room, located next to the kitchen. A washer and dryer in good condition and LPA observed both were running washing and drying cloths.

Medications: At approximately, 12:05 PM LPA observed medications are centrally stored and were locked near the dining room cabinet.

Bedrooms: The facility has four (4) bedrooms. Two (2) are private and two (2) are shared. All bedrooms contained a nightstand, storage, and bed with adequate bedding. All furnishings were clean and in good condition. Bedroom # one (1) and bedroom # three (3) were vacant.

Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HARTLAND CARE, INC.
FACILITY NUMBER: 197608678
VISIT DATE: 03/14/2024
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Bathrooms: The facility has two (2) bathrooms. One of the bathrooms is designated for staff and the other for residents. The bathroom designated for residents contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight-fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At 12:12 PM, hot water temperature measured at 117.2°F. A closet in the hallway contained a sufficient supply of fresh linens.

Common Areas: The facility maintains a comfortable temperature at 73°F. The living room and dining area appeared clean and were properly furnished. The living room has a television, comfortable furniture. No obstructions and or tripping hazards throughout the facility.

Smoke detectors/carbon monoxide. At 12:15 PM, LPA tested the dual-function smoke and carbon monoxide detector to be operational. Two (2) out of two (2) detectors were functioned during the test, and an additional verbal alert sounded.

Outside areas: At approximately, 12:20 LPA toured the outside area of the facility. LPA observed a covered patio area outside with furniture in good repair. The emergency exit was unlocked with an inward facing latch. Emergency exit paths were free from debris.

The garage is attached to the home without an excess from the home and is kept locked inaccessible to residents.

Between 12:30 PM to 2:15 PM, LPA reviewed records of three (3) residents and three (3) staff. Residents and staff records appeared to be complete and updated.

Administrative: LPA collected Certificate of Liability Insurance, and LIC500.

Exit interview conducted and copy of this report signed and delivered. No citations issued.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
LIC809 (FAS) - (06/04)
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