197609081-3-3-2022-28-AS-NMAN-CC6S5F-20220303123415

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609081
Report Date: 03/03/2022
Date Signed: 03/03/2022 12:34:20 PM

Document Has Been Signed on 03/03/2022 12:34 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	OAKRIDGE INN 2		FACILITY NUMBER:	197609081
ADMINISTRATOR:	PETROSYAN, KHACHIK		FACILITY TYPE:	740
ADDRESS:	1225 OAKRIDGE DRIVE		TELEPHONE:	(818) 482-9117
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91205
CAPACITY:	6	CENSUS: 6	DATE:	03/03/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Staff Ruzanna Javadyan and Administrator Romik Rostomyan		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) Nune Margaryan conducted an annual required visit. LPA met with staff Ruzanna Javadyan. Shortly after Administrator Romik Rostomyan arrived. Reason for the visit was explained. LPA used the infection control tool to evaluate the facility. LPA inspected the physical plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed resident and staff files. There are currently six (6) residents who reside at this facility, the facility has a hospice wavier for three (3) and currently has no residents on hospice.

There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask upon entrance and during visit.

LPA inspected the interior and the exterior of the facility with Administrator Romik Rostomyan including but not limited to: the common living spaces, resident bedrooms (4); bathrooms (2), kitchen, laundry area, backyard and garage. Bathrooms and bedrooms were clean and in good repair. There is a locked storages for medications in the kitchen area and toxins in the laundry area. The kitchen was toured. All appliances were operating properly. There was a sufficient amount of perishable and non-perishable food. Kitchen knives are stored in a locked drawer in the kitchen. The common areas including the living rooms and dining room are clean and have the required furniture. The backyard has a shaded area and sitting area. The facility has cameras in the hallway and common areas only. All residents bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space. Both bathrooms were toured. Bathrooms have the required grabs bars and non-skid mats. The hot water was 108.9 degrees which is within the required 105 - 120 degrees.

Continue 809C

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

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 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: OAKRIDGE INN 2	FACILITY NUMBER: 197609081
	VISIT DATE: 03/03/2022

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
26
27
28
29
30
31
32

LPA reviewed 6 resident files to confirm emergency contact is updated. LPA also reviewed staff files to confirm health screenings and fingerprint clearances. All staff files reviewed were fingerprint cleared. LPA reviewed residents' medications. Medications are documented properly and stored appropriately. Facility first aid kit was checked and in compliance.

Based on California Code of Regulations, Title 22, there were no deficiencies observed during the visit. A copy of the report was provided to the administrator.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2