197609298-9-17-2024-29-AS-EMOY-D97VMS-20240917163400

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609298
Report Date: 09/17/2024
Date Signed: 09/17/2024 04:34:16 PM

Document Has Been Signed on 09/17/2024 04:34 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	MOM AND DADS RETREAT INC		FACILITY NUMBER:	197609298
ADMINISTRATOR:	ARMENUI AMY ARZUMANYAN		FACILITY TYPE:	740
ADDRESS:	15214 WYANDOTTE STREET		TELEPHONE:	(818) 390-7012
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY:	6	CENSUS: 5	DATE:	09/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	ARMENUI AMY ARZUMANYAN		TIME COMPLETED:	04:40 PM

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Licensing Program Analysts (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 10:00 a.m. Upon arrival, LPA Mosley was greeted by staff and administrator and informed them of the visit. The LPA met with Administrator ARMENUI AMY ARZUMANYAN and explained the reason for the visit. The LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.
The facility is a single story home located in the back of the property consisting of 2 separate buildings with separate addresses. The home consists of a living room, dining room, kitchen, a den, 5 bedrooms and 4 full bathrooms.

COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 1:45 p.m., smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was observed fully charged and purchased on 08/02/2024. The LPAs observed required postings throughout the common space. The last emergency disaster drill took place on 07/15/2024. Activities were observed in the common areas.

KITCHEN: The LPA inspected the kitchen/food service area at 11:05 a.m. Knives and sharps were observed in a lock box in a drawer. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 114.8 degrees Fahrenheit at 11:09 a.m. Complete first aid kit and manual was observed at 11:06 a.m. LPA observed an adequate amount of emergency food and water in the food pantry.

Report Continued on LIC 809C...

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MOM AND DADS RETREAT INC	FACILITY NUMBER: 197609298
	VISIT DATE: 09/17/2024

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Report Continued from LIC 809...
BEDROOMS: There are 5 (five) total bedrooms in the facility; one (1) is designated as a shared room, four (4) are designated as private resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There is a washer and dryer on premises. Laundry detergent was observed in a locked cabinet above the washer and dryer.

RESTROOMS: The resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured; the first private restroom measured at 114.2 degrees Fahrenheit at 11:13 a.m. The hot water temperature was measured; the second private restroom measured at 114.3 degrees Fahrenheit at 11:18 a.m. the third (3) private restroom measured at 115.2 degrees Fahrenheit at 11:26 a.m. The fourth (4) shared restroom measured at 114.2 at 11:32 a.m. all restrooms within the required range.

BACKYARD/ OUTDOOR AREA: The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. LPA observed one (1) self-latching gate. There were no bodies of water noted at the time of the visit.

MEDICATIONS: Medications review began at approximately 2:45 p.m. The medications are locked in a cabinet adjacent to the kitchen. Medications for five (5) residents were reviewed. Medications reviewed were found to be self administered as prescribed and documented on the centrally stored medication and destruction records.

RECORDS: Resident Records were reviewed beginning at 11:45 a.m. and personnel records at 12:45 p.m. five (5) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan.

Report Continued from LIC 809C...

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MOM AND DADS RETREAT INC	FACILITY NUMBER: 197609298
	VISIT DATE: 09/17/2024

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Report Continued from LIC 809...

Six (6) personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order.

INTERVIEWS: One (1) staff interview was conducted. Five (5) resident interviews were attempted, and three (3) interviews were conducted during the inspection.

DOCUMENTS: Documents obtained during inspection include liability insurance and LIC 9020.

No deficiencies were cited during today’s inspection. Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

LIC809 (FAS) - (06/04)

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