197608760-9-24-2021-29-AS-SURA-C76TVY-20210924150443

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608760
Report Date: 09/24/2021
Date Signed: 09/24/2021 03:05:12 PM

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:	NOBLE CARE		FACILITY NUMBER:	197608760
ADMINISTRATOR:	ARMINE TAGARYAN		FACILITY TYPE:	740
ADDRESS:	13300 ARMINTA STREET		TELEPHONE:	(818) 616-2427
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY:	6	CENSUS: 6	DATE:	09/24/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	ArmineTagaryan		TIME COMPLETED:	03:00 PM

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At 1:25 pm, Licensing Program Analyst (LPA) Sandra Urena arrived at facility, to conduct an unannounced required annual inspection visit. The LPA introduced herself to administrator Armine Tagaryan and explained the reason for the visit.

INFECTION CONTROL: Upon entry, the facility has a sign in book and sanitizing gel. Infection Control signage was visible at entrance. Temperature was taken by caregiver and the LPA was asked to sign in.

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

At 1:45pm, the LPA toured the living area and common area and found them to be appropriately furnished and in good condition.

Kitchen: At 1:50 pm, the LPA observed the kitchen/dining area. Knives are stored in a locked cabinet drawer. Kitchen appliances were in operable condition. The facility has enough supply of perishable and non-perishable food. Freezer and refrigerator are stocked with a variety of foods. Emergency food supply is adequate for six residents and two staff.

Bedrooms: At 2:15 pm, LPA inspected the residents’ bedrooms. Facility has four (4) bedrooms. Two bedrooms are shared, and two bedrooms are single occupancy. Bedrooms were furnished appropriately with appropriate furnishings, bedding, and sufficient lighting.

Bathrooms: At 2:30 pm, LPA inspected the residents’ bathrooms. The facility has three (3) bathrooms. Two are for residents, and one bathroom for caregivers and visitors. The shower areas were in clean condition with grab bars and non-skid mats available. Soap, and paper towels were available for drying hands. Hand washing signs were displayed.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021

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: NOBLE CARE	FACILITY NUMBER: 197608760
	VISIT DATE: 09/24/2021

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Outdoor Space: At 2:45 pm, the LPA observed the backyard of the facility to be free of clutter and debris. There is a pool which is fenced in and inaccessible from residents.

Facility Records: At 3:00 pm, the LPA observed records for residents and staff to be complete and accurate at the time of this visit.

The LPA observed 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 a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies were cited at this time. Exit interview conducted. Signatures obtained. A copy of report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021

LIC809 (FAS) - (06/04)

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