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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609106
Report Date: 06/02/2022
Date Signed: 06/02/2022 04:08:04 PM

Document Has Been Signed on 06/02/2022 04:08 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ASHNAR HOMEFACILITY NUMBER:
197609106
ADMINISTRATOR:HAKOBYAN, MARINEFACILITY TYPE:
735
ADDRESS:14131 PIERCE STTELEPHONE:
(818) 834-7919
CITY:ARLETASTATE: CAZIP CODE:
91331
CAPACITY: 4CENSUS: 4DATE:
06/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:07 PM
MET WITH:MARINE HAKOBYAN TIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Tihesha “Lynn” Smith conducted an unannounced annual/infection control visit to this facility at 12:07 pm and observed COVID signs on the front door. LPA was greeted by caregiver Rita Avetikyan and temperature was taken and recorded. The administrator was called at 12:10 and arrived later.

LPA reviewed files for staff and clients between 12:35 pm -1:20 pm. Client files were reviewed and observed to be complete and current at time of visit. Staff files included current first aid and CPR certifications as well as sufficient training documentation.

LPA conducted a tour of the physical plant between 1:20-2:40 PM to ensure there are no health and
safety hazards and facility staff are following Title 22 Regulations.

LPA was escorted to the living area. The living area had furnishings and sufficient lighting and observed to be clean with adequate seating for clients. LPA was escorted to kitchen/dining combination area. The area was clean and well kept. The kitchen food supply was observed and sufficient for the four (4) clients currently residing there. Two (2) days of perishable fruits, vegetables, milk, and eggs observed. The freezer is stocked with meats, poultry, and frozen vegetables. There is a supply of canned foods, dried foods, and water in a side storage area off kitchen back door.

Sharps and cleaning supplies are locked in cabinet under kitchen sink. The medications and fully stocked first aid kit are locked in kitchen island cabinet. Medication observed to be properly labeled. Client medications and records reviewed and consistent with the centrally stored medication log.

The laundry room located to the left of hallway observed to be clean and appliances in good repair. Two (2) locked cabinets above washer and dryer store toiletry/hygiene back stock and laundry detergents. There is a sufficient supply of linens and PPEs in laundry room pantry.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2022
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ASHNAR HOME
FACILITY NUMBER: 197609106
VISIT DATE: 06/02/2022
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( Cont from 809)

There are four (4) bedrooms designated for clients use. All bedrooms were clean, properly furnished and had sufficient lighting. There were three (3) bathrooms designated for clients use. All bathrooms were clean, properly supplied and had functional fixtures. The water temperature range between 105 and 120-degrees Fahrenheit.

The smoke alarms and carbon monoxide detectors were present and function properly. Fire
extinguisher on kitchen wall fully charged.

There is a separate structure in the backyard which is locked staff area. The covered patio observed to be clean and furnished with adequate seating for clients. The grounds entry/exits area were clean with and free of obstruction.

There are no deficiencies to report.

Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Emailed.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC809 (FAS) - (06/04)
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