197609106-12-20-2023-31-AS-MCAA-CYPQRG-20231220112354

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609106
Report Date: 12/20/2023
Date Signed: 12/20/2023 11:24:03 AM

Document Has Been Signed on 12/20/2023 11:24 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ASHNAR HOME		FACILITY NUMBER:	197609106
ADMINISTRATOR:	HAKOBYAN, MARINE		FACILITY TYPE:	735
ADDRESS:	14131 PIERCE ST		TELEPHONE:	(818) 834-7919
CITY:	ARLETA	STATE: CA	ZIP CODE:	91331
CAPACITY:	4	CENSUS: 3	DATE:	12/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:59 AM
MET WITH:	Knarik Manukyan, Marine Hakobyan		TIME COMPLETED:	11:30 AM

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) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with staff, Knarik Manukyan and explained the reason for the visit. Administrator, Marine Hakobyan, joined shortly after. At 9:15am, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms and carbon monoxide detectors are dual and function properly. Fire extinguishers are located at the kitchen and hallway by the resident's room. The charge date is 06/13/23. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly labeled stored. Knives were inaccessible. Cleaning supplies stored and locked underneath the kitchen sink. Properly labeled medications were locked in one of the kitchen cabinets. Bedrooms: There were four (4) bedrooms. Three (3) are designated for residents' use. One bedroom is for staff. The bedrooms, in use by residents were were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are four (4) bathrooms. three (3) bathrooms are designated for residents' use, and one bathroom is designated for staff. The bathrooms designated for resident use were properly supplied and had functional fixtures. Hot water temperature was measured at 120 degrees Fahrenheit. No cleaning supplies stored in the bathroom.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ASHNAR HOME	FACILITY NUMBER: 197609106
	VISIT DATE: 12/20/2023

NARRATIVE

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Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit.

Surrounding Grounds: Entry/exits were free of obstruction. There is a patio/bbq area in the backyard with furniture appropriate for outdoor use. There was enough space in the front and backyard to hold outdoor activities. The outdoor area was free of hazards.

Laundry/storage: The laundry area is located in the hallway, by resident rooms. There are locked cabinets where detergents and cleaning supplies are stored. In addition, the laundry area is equipped with a locked door, making it inaccessible for residents to enter.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records are stored in a locked cabinet in the kitchen. Medications were review for proper storage and documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
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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