197608954-12-21-2023-29-AS-SURA-CYR22C-20231221160027

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608954
Report Date: 12/20/2023
Date Signed: 12/21/2023 04:01:18 PM

Document Has Been Signed on 12/21/2023 04:01 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:	LIEBELOVE CARE INC		FACILITY NUMBER:	197608954
ADMINISTRATOR:	GALINA MELKONYAN		FACILITY TYPE:	740
ADDRESS:	6500 QUARTZ AVENUE		TELEPHONE:	(747) 888-9984
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 6	DATE:	12/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:33 AM
MET WITH:	Galina Melkonyan		TIME COMPLETED:	04:30 PM

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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual visit at 10:45 a.m. The LPA was greeted by staff. Staff informed Administrator about the visit. The Administrator arrived shortly thereafter. The LPA met with Administrator Galina Melkonyan and explained the reason for the visit.

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

KITCHEN: Knives and chemicals were locked inaccessible in the kitchen cabinet. Appliances were in operable condition. The facility had a sufficient supply of perishable and non-perishable food. Fire extinguisher was located by the kitchen area and was last purchased on 10/13/2023.

COMMON SPACES: At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature of 72 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The LPA observed required postings throughout the common spaces.

BEDROOMS: The facility has six (6) residents’ bedrooms. All bedrooms are private bedrooms. Bedrooms were furnished appropriately; beds were observed with clean linens and rooms had sufficient lighting. The facility has one common area between bedroom #4 and bedroom #5. All direct exits were clear, and no obstructions were noted.

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: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

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: LIEBELOVE CARE INC	FACILITY NUMBER: 197608954
	VISIT DATE: 12/20/2023

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RESTROOMS: The facility has three (3) common restrooms. One restroom by the entrance hallway, one restroom next to bedroom #1; this restroom is utilized to shower the residents. One restroom is between bedrooms #4 and #5. Restrooms were clean and sanitary with grab bars and non-skid surfaces. At 2:30 PM., water temperature measured at ...degrees Fahrenheit. Restrooms were fully stocked. Hand-washing signs were observed in all restrooms. All restrooms need trash cans with covers.

OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate for client use and is single-latched. No bodies of water noted. The washer and dryer appeared operational and are located in the garage. Administrator agreed to remove two old mattresses and two commodes observed in the backyard.

RECORDS: Records review began at 1:17 p.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 2:00 p.m.; medications are centrally stored and locked in two top cabinets in the kitchen area; medications are labeled and 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: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

LIC809 (FAS) - (06/04)

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