197609503-1-12-2023-29-AS-SURA-CMZSKB-20230112125625

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609503
Report Date: 01/12/2023
Date Signed: 01/12/2023 12:59:19 PM

Document Has Been Signed on 01/12/2023 12:59 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:	BEN ASSISTED LIVING		FACILITY NUMBER:	197609503
ADMINISTRATOR:	AYVAZYAN, ZHIRAYR		FACILITY TYPE:	740
ADDRESS:	7757 BEN AVENUE		TELEPHONE:	(818) 212-5050
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY:	6	CENSUS: 5	DATE:	01/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Zhirayr Ayvazyav		TIME COMPLETED:	12:30 PM

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On 01/12/2023, Licensing Program Analyst (LPA) Sandra Urena, arrived at the facility unannounced to conduct a required annual inspection. LPA Urena arrived at the facility at 10:00 a.m. This annual had a specific emphasis on infection control practices, and procedures. The purpose of the inspection was discussed with the administrator Zhirayr Ayvazyan.

Infection Control: Upon entry, the facility has a sign in book and sanitizing gel. Infection Control signage was visible at entrance. Temperature was checked and recorded.

From 10:30 a.m. to 11:15 a.m. LPA Urena and administrator conducted a tour inside and outside of the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Common Areas: Common seating area and dining room furniture were observed to be in good condition. Fire extinguishers were observed to be serviced within the last year.

Kitchen: Knives are stored in a locked cabinet drawer. Kitchen appliances were in operable condition. The facility has enough supply of perishable and non-perishable food. Freezer and refrigerator are stocked with a variety of foods. Emergency food supply is adequate for six residents and two staff.

Continues on LIC 809C...

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BEN ASSISTED LIVING	FACILITY NUMBER: 197609503
	VISIT DATE: 01/12/2023

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Bedrooms: Bedrooms were furnished appropriately with appropriate furnishings and sufficient lighting. Linens are clean, and in good condition.

Bathrooms: Bathrooms were clean, shower area was in clean condition with grab bars and a non-skid mat available. Paper towels were available for drying hands. Hand washing signs were displayed, and sufficient amounts of soap and paper products in each restroom.

Outdoor Space: Backyard has a covered outdoor area equipped with furniture in good repair for residents’ use. There were no bodies of water noted. Side gate is unlocked.

LPA Urena observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate

No citations were issued. Exit interview was conducted, the report was reviewed with the administrator and a copy of the report was provided. Signatures were obtained.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

LIC809 (FAS) - (06/04)

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