197608760-10-5-2023-29-AS-SURA-CWBSP7-20231005140236

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608760
Report Date: 10/05/2023
Date Signed: 10/05/2023 02:03:09 PM

Document Has Been Signed on 10/05/2023 02:03 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 N.ASC, 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: 5	DATE:	10/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Armine Tagryan		TIME COMPLETED:	02:00 PM

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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required Annual inspection at 10:00 a.m. The LPA met with Administrator Armine Tagaryan and explained the reason for the visit.

The LPA, and the administrator 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.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature of 75 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. One fire extinguisher was fully charged and was last serviced 08/30/2023. The LPA observed required postings throughout the common space.

KITCHEN: 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. The hot water temperature measured at 110.5 degrees Fahrenheit.

BEDROOMS: Facility has four (4) bedrooms. One bedroom is shared, and three (3) bedrooms are private. Bedrooms were furnished appropriately with appropriate furnishings, bedding, and sufficient lighting.

BATHROOMS: The facility has three (3) bathrooms. Two bathrooms are for residents, and one bathroom for staff, 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.The hot water temperature measured at 110.5 degrees Fahrenheit.

Continues on LIC 809C...

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: NOBLE CARE	FACILITY NUMBER: 197608760
	VISIT DATE: 10/05/2023

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OUTDOOR SPACE: The LPA observed the backyard of the facility to be free of clutter and debris. Outdoor furniture and a shaded area are available for residents. There is a pool which is fenced in, and inaccessible from residents.

RECORDS: Records review began at 11:45 a.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 12:30 p.m.; medications are centrally stored and locked in a file cabinet in the office area; medications are labeled and were checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

INFECTION CONTROL: 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 a single isolation room if the facility has a confirmed case of COVID-19.

The LPA reviewed the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster

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

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

LIC809 (FAS) - (06/04)

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