197608986-7-13-2022-29-AS-BBAI-CG9QKU-20220712121454

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608986
Report Date: 07/12/2022
Date Signed: 07/13/2022 08:00:14 AM

Document Has Been Signed on 07/13/2022 08:00 AM - It Cannot Be Edited

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:	AGE WELL ASSISTED LIVING FACILITY		FACILITY NUMBER:	197608986
ADMINISTRATOR:	SARKIS DOVLATYAN		FACILITY TYPE:	740
ADDRESS:	15149 SYLVAN STREET		TELEPHONE:	(818) 666-1665
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91411
CAPACITY:	6	CENSUS: 5	DATE:	07/12/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Wynn Apao		TIME COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Brian Balisi arrived to this facility today to conduct a One (1) year Required inspection of this facility with emphasis on infection control practices and procedures. LPA met with caregiver Wynn and explained the reason for the visit. LPA spoke with Administrator Sarkis over the phone, who stated it was okay for Wynn to sign for the report. A tour of the physical plant was conducted with Wynn approximately between 10:30am - 12:30pm LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. The following was noted: The facility has three (3) bedrooms and two (2) bathrooms currently occupying five (5) residents. One (1) bathroom is designated for staff use. All smoke alarms and carbon monoxide detector were tested and functioned properly during time of visit. LPA observed all required postings in the living area. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility; Sharp objects are stored in a locked drawer to the right of the dishwasher. Medication is stored in a locked cabinet above the dishwasher. Bedrooms: The resident bedrooms were properly furnished with at least one chair, night stand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022

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: AGE WELL ASSISTED LIVING FACILITY	FACILITY NUMBER: 197608986
	VISIT DATE: 07/12/2022

NARRATIVE

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Bathrooms: LPA observed all bathrooms were clean, properly supplied and had functional fixtures. LPA observed grab bars and non-skid mats in the bathroom Residents have sufficient amounts of supplies for personal hygiene stored in the designated staff bathroom. The hot water was measured in each bathroom during physical plant tour. Hot water measured within the required limit of 105-120 degrees Fahrenheit in all bathrooms during visit. Laundry area was located in the staff bathroom as well. Cleaning supplies were observed stored in locked cabinets inaccessible to residents in care.

Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. At 11am, LPA observed (3) residents watching television in the living room area. There is a entry closet located by the front door. LPA observed non-perishables, emergency supplies and PPE stored here at this time.

Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use in the front and rear of the facility. There are no bodies of water on the premises. There was an Adult Dwelling unit located in the rear of the facility. LPA observed unit to be empty at this time and inaccessible to residents.At 12pm, LPA observed residents having lunch at dining table.

The LPA spoke with Wynn regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. 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 bedroom #1 as a single isolation room if the facility has a confirmed case of COVID-19. COVID-19 testing is conducted weekly if anyone shows any symptoms. The facility’s policies and procedures as it pertains to infection control are adequate at this time.

Exit interview conducted, report issued and sent via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022

LIC809 (FAS) - (06/04)

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