197609503-2-8-2024-29-AS-SURA-D2A27H-20240208160846

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609503
Report Date: 02/07/2024
Date Signed: 02/08/2024 04:09:07 PM

Document Has Been Signed on 02/08/2024 04:09 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:	AYVAZYAN, ZHIRAYR		FACILITY TYPE:	740
ADDRESS:	7757 BEN AVENUE		TELEPHONE:	(818) 212-5050
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY:	6	CENSUS:	DATE:	02/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Zhirayr Ayvazyan		TIME COMPLETED:	04:18 PM

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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual inspection. LPA Urena arrived at the facility and was greeted by staff. The administrator arrived shortly thereafter. The purpose of the inspection was discussed with the administrator Zhirayr Ayvazyan.

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 AREA: 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. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature of 72 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was purchase on 03/22/2023. The LPA observed required postings throughout the common space. The washer and dryer are locked in the hallway. Cleaning supplies and disinfectants are kept locked in the washer and dryer area.

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. The freezer and refrigerator are stocked with a variety of foods. The emergency food supply is adequate for six residents and two staff.

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. Continues on LIC 809C...

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024

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: BEN ASSISTED LIVING	FACILITY NUMBER: 197609503
	VISIT DATE: 02/07/2024

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OUTDOOR: Backyard has a covered outdoor area equipped with furniture in good repair for residents’ use. There were no bodies of water noted. There is a side gate and is single-latched.

RECORDS: Records review began at 3:00 p.m, Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 3:30 p.m.; medications are centrally stored and locked in a cabinet in the common area; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

INFECTION CONTROL: The facility has 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 LPA reviewed the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024

LIC809 (FAS) - (06/04)

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