197609503-2-5-2025-29-AS-TBYE-DDLTYA-20250205140824

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609503
Report Date: 02/05/2025
Date Signed: 02/05/2025 02:08:36 PM

Document Has Been Signed on 02/05/2025 02:08 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BEN ASSISTED LIVING		FACILITY NUMBER:	197609503
ADMINISTRATOR/ DIRECTOR:	AYVAZYAN, ZHIRAYR		FACILITY TYPE:	740
ADDRESS:	7757 BEN AVENUE		TELEPHONE:	(818) 212-5050
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	02/05/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:16 AM
MET WITH:	Zhirayr Ayvazyan		TIME VISIT/ INSPECTION COMPLETED:	02:15 PM

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) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:16 AM. LPA met with facility administrator Zhirayr Ayvazyan. Entrance interview conducted and the reason for the visit was explained. Beginning at 09:17 AM, the LPA, along with facility Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: BEDROOMS: There are three (3) bedrooms in the facility; two (2) are a dual occupancy resident rooms and one (1) is a single occupancy resident room. LPA and facility administrator toured all three (3) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. BATHROOMS: There are two (2) bathrooms at the facility. One (1) bathroom is designated as private resident bathroom, and one (1) bathroom is designated as a shared resident bathroom. Both resident bathrooms were observed to be clean and in good repair and were equipped with nonskid surfaces. Grab bars were observed in resident showers and near all resident toilets, all were properly secured. The water temperature was measured at 118.7 degrees Fahrenheit, which is in compliance with regulation. LPA observed the private resident bathroom to contain an appropriately secured under-sink cabinet containing personal grooming supplies for resident use. Continued on LIC 809C.

Kasandra Lopez	TELEPHONE: (818) 596-4343
Trevor Byrne	TELEPHONE: 747-444-6104
	DATE: 02/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025

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: BEN ASSISTED LIVING	FACILITY NUMBER: 197609503
	VISIT DATE: 02/05/2025

NARRATIVE

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KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured drawer to contain knives and other sharp objects. LPA observed a secured cabinet to contain resident medications and resident files. LPA observed a complete first aid kit and a fire extinguisher that was purchased on 11/12/2024.

COMMON AREAS: This includes the living room, laundry room, storage room, and dining area. LPA observed the dining area to be clean and properly furnished at the time of the visit. The dining room contains a dining table with adequate seating for resident use. The living room was observed to be clean and in good repair. The living room contained adequate seating for resident use. LPA observed the living room to contain an adequately screened fireplace. A camera was observed in the living room, the Administrator informed LPA that the camera does not record audio. LPA observed the laundry room to contain a washer and dryer and an appropriately secured cabinet to contain laundry chemicals. LPA observed an appropriately secured storage room to contain cleaning supplies and extra care supplies. The facility’s combination fire and carbon monoxide alarms were tested at 11:33 AM and were functional at the time of the visit. All exits in the facility were observed to contain functioning auditory alarms.

OUTDOOR SPACE: The facility has one (1) emergency exit gate located in the front yard. LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. LPA observed a deck and ramp at the back of the facility. The deck and ramp were equipped with sturdy railings and sufficient lighting.

RECORD REVIEW: Record review began at 09:55 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Five (5) staff files were reviewed. All staff files contained the required documents and trainings. Five (5) resident files were reviewed. All resident files were observed to contain all required documentation and signatures. No deficiencies were observed during record review.

Continued on LIC 809C.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor Byrne	TELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 02/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025

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: BEN ASSISTED LIVING	FACILITY NUMBER: 197609503
	VISIT DATE: 02/05/2025

NARRATIVE

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MEDICATION REVIEW: Medication review began at 11:35 AM. Medications for four (4) of five (5) residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the
facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 02/02/2025. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s administrator.

INTERVIEWS: LPA interviewed three (3) residents. The residents interviewed stated that the staff treat them very well and are attentive to their needs. All residents interviewed were satisfied with the care the facility provides and had no concerns with the facility. LPA interviewed one (1) staff member; this interview was conducted with the assistance of the facility Administrator acting as a translator. The staff member interviewed was knowledgeable on the resident's rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse.

During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and liability insurance.

No deficiencies were observed during today’s inspection. Exit interview conducted and copy of the report was issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor Byrne	TELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 02/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025

LIC809 (FAS) - (06/04)

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