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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608756
Report Date: 10/12/2024
Date Signed: 10/12/2024 04:06:23 PM


Document Has Been Signed on 10/12/2024 04:06 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
Lookup Error,
, CA



FACILITY NAME:ANGEL LIFE CAREFACILITY NUMBER:
197608756
ADMINISTRATOR:MICHAEL PETROSIANFACILITY TYPE:
740
ADDRESS:407 ETON DRIVETELEPHONE:
(818) 478-1792
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY:6CENSUS: 5DATE:
10/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:41 PM
MET WITH:Mikayel Gurokyan TIME COMPLETED:
04:19 PM
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Licensing Program Analyst (LPA) Alberto Lopez conducted the required annual inspection. LPA arrived unannounced and DSP Gaynane Petrosian who allow entry and Mikayel Gurokyan, house manager arrived short time later and LPA explained the purpose of the visit. The facility is licensed for residents ages 60 and over, may retain a maximum of six (6) hospice residents, and six (6) bedridden. Currently facility has 0 hospice residents. The home is for Developmentally Disabled, Level 4D. Currently there is one resident over 60 years of age and 4 residents under 60 years of age.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan.

2. Operational Requirement: Liability Insurance is updated and in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place.

3. Physical Plant and Environmental Safety: The facility is a single-story house and located in a residential neighborhood area. The facility includes Dining area, kitchen, sitting room, five (5) residents bedrooms, two (2) resident bathrooms, laundry room, detached garage. Each resident bedroom has one bed, dresser, required beddings and furniture and sufficient lighting and closet space. The two residents bathrooms are clean, sanitary and in a good working condition. Both bathrooms have the required grab bar and non-skid mat. The two bathrooms hot water temperature were tested between 107.0 and 111.0 degrees F. which is within the Tittle 22 regulation. All the appliances in the kitchen and living room are working well. The sharp knives are stored in a locked kitchen drawer. (Continue on 809C)
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: ANGEL LIFE CARE
FACILITY NUMBER: 197608756
VISIT DATE: 10/12/2024
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(continue from 809)
All the cleaning supplies and chemicals are stored and locked in a cabinet in the laundry room area The linen and towels are stored in the hallway cabinet. The extra personal hygiene products are stored in the locked cabinet in the hallway. The carbon monoxide detectors were inspected, and they are working properly. The facility has table and chairs for resident to utilize outdoor activity. The Passageway, walkway and patio are free of obstruction.

4. Staffing: The facility has sufficient staffing, and the night supervision staff have current CPR/first aid certification.

5. Personnel Record-Training: All the staff files are maintained in the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. All the direct care staff have ongoing Medication Management and other required Training.


6. Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Pre-admission appraisal/Appraisal Needs & Services Plan.
7. Resident Rights-Information: The Complaint, ombudsman and CCLD poster and Residents personal rights are posted by the main entry. Visiting hours are included in admission agreement.
8. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability.
9. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be very clean and sanitary. The food is properly stored in the refrigerator (clean, labeled and well maintained). Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept very clean and free from rodents.
10. Incidental Medical and Dental: The medication is centrally stored and locked in the medication cabinet in the hallway. Five (5) centrally stored resident medications were reviewed, which contained 30-day supply of medications. Facility will provide transportation to resident for medical and dental appointment if needed.
11. Disaster Preparedness: The last fire drill was conducted on 10/02/24.. The facility has an Emergency Disaster Plan (LIC610E) dated on 10/01/24 that needs to be updated. The facility has two alternative temporary shelter location.
12. Resident with Special Health Needs: No residents are receiving home health services. No resident is currently on postural support. Individual Service Plans and Appraisals are on file.

No deficiency observed during today’s visit. Technical Advisory provided. An exit interview was held. A copy of this report, and appeal rights were provided.

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2024
LIC809 (FAS) - (06/04)
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