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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609298
Report Date: 08/07/2022
Date Signed: 08/07/2022 03:28:23 PM


Document Has Been Signed on 08/07/2022 03:28 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. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:MOM AND DADS RETREAT INCFACILITY NUMBER:
197609298
ADMINISTRATOR:ARMENUI AMY ARZUMANYANFACILITY TYPE:
740
ADDRESS:15214 WYANDOTTE STREETTELEPHONE:
(818) 390-7012
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY:6CENSUS: 5DATE:
08/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Amy ArzumanyanTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a required annual visit. This annual had a specific emphasis on infection control practices. The LPA initially met with staff, whom contacted the Administrator. The LPA spoke with Administrator Amy Arzumanyan over the phone, whom arrived shortly after. The LPA, along with staff, toured the facility to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Knives and chemicals are locked inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: Bedrooms had appropriate furniture, clean linens and sufficient lighting. Rooms were clean and clear of obstructions. RESTROOMS: The restrooms were clean and sanitary with grab bars and non-skid surfaces. At 2:30 p.m., water temperature measured at 111.7 F. Restrooms were stocked with soap and paper towels. COMMON SPACES: The facility maintained a temperature of 71 degrees. Medications were kept locked in a cabinet in the kitchen. Smoke detectors and carbon monoxide detectors were operable. Living room and dining furniture were observed in good condition. The fireplace was covered and inaccessible. The backyard had furniture and a covered area. No obstructions observed in the exterior or interior. No bodies of water noted.

INFECTION CONTROL: There is a central entry point for screening and temperature checks. Appropriate infection control signage was observed throughout the facility. The facility’s cleaning protocol is sufficient. There is record of staff and resident vaccinations. The facility can designate a room to isolate persons if there is a confirmed case of COVID-19. Staff are up to date regarding guidelines around visitation and vaccine requirements. The facility has a sufficient supply of Personal Protection Equipment (PPE) and can obtain additional supplies as needed. The facility continues to conduct weekly surveillance testing at this time. The policies and procedures pertaining to infection control were adequate.

No deficiencies cited. Exit interview conducted. Report issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2022
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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