197609553-7-9-2021-29-AS-EPEI-C4RV5A-20210709160738

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609553
Report Date: 07/09/2021
Date Signed: 07/09/2021 04:09:05 PM

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:	ANO TWO FACILITY FOR THE ELDERLY		FACILITY NUMBER:	197609553
ADMINISTRATOR:	CHAMCHYAN, NEKTAR		FACILITY TYPE:	740
ADDRESS:	7905 STANSBURY		TELEPHONE:	(818) 650-8140
CITY:	PANORAMA CITY	STATE: CA	ZIP CODE:	91402
CAPACITY:	6	CENSUS: 4	DATE:	07/09/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	NEKTAR CHAMCHYAN		TIME COMPLETED:	04:15 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	At 2:10 pm, Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. LPA was greeted and screened by Administrator, Nektar Chamchyan. This annual had a specific emphasis on infection control practices and procedures. At 2:20 pm, LPA 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. OUTDOOR SPACE: LPA observed the front patio, which has a covered outdoor area for resident use. There is a gate on the side of the house designated for an emergency exit. KITCHEN: At 2:25 pm, LPA observed the kitchen/dining area. Knives are stored in a locked cabinet. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. RESTROOMS: Resident restroom is clean and sanitary and in operating condition with grab bars and non-skid mat. Common Areas: LPA observed common area to be relatively clean and properly furnished. At 2:35 pm, LPA observed staff cleaning resident restroom. LPA observed the fire extinguisher to be fully charged and last serviced on 09/04/2020. Medications and first aid kit were locked in a cabinet near the living area. Continued on LIC 809-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

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: ANO TWO FACILITY FOR THE ELDERLY	FACILITY NUMBER: 197609553
	VISIT DATE: 07/09/2021

NARRATIVE

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Continued from LIC 809.

Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away.

Records: At 2:54pm, LPA requested records for Resident 1(R1). R1 records were up to date and Administrator provided missing resident records.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station. LPA observed a 30-day 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 has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate.

The following recommendations were made:

- Ensure that all resident records are up to date, including hospice care plans.

Between 3:00 pm - 3:30 pm, LPA conducted Infection Control mitigation module with Administrator.

At 4:05pm, exit interview conducted. Report issued and a copy of the report will be provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

LIC809 (FAS) - (06/04)

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