197609553-8-2-2022-29-AS-EPEI-CGWRD9-20220802125535

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609553
Report Date: 08/02/2022
Date Signed: 08/02/2022 12:56:29 PM

Document Has Been Signed on 08/02/2022 12:56 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:	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: 3	DATE:	08/02/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:14 AM
MET WITH:	Armine Tagaryan		TIME COMPLETED:	01:00 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) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 11:14 a.m., the LPA met with staff and explained the reason for the visit. The Administrator, Artur Atoyan authorized staff Armine Tagaryan to sign the report. The Administrator was unavailable during the time of the visit. This annual had a specific emphasis on infection control practices and procedures. At 11:15 a.m., the LPA, along with staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. KITCHEN: The LPA observed the kitchen/dining area. Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 11:16 a.m., hot water measured at 115.2-degree Fahrenheit. Medications and first aid kits are located in a locked cabinet near the kitchen area. COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished. The LPA observed the fire extinguisher to be fully charged and last serviced on 09/13/2021. Signs are posted throughout facility to promote handwashing, and cough/sneeze etiquette. At 11:27 a.m., fire alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed cameras in the common areas, and throughout the exterior perimeter of the facility. BEDROOMS: The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. At 11:24 a.m., hot water measured at 106.0-degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels. 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: 08/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

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: 08/02/2022

NARRATIVE

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OUTDOOR SPACE: At 11:32 a.m., the LPA observed the back and 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. Passageways were free and clear from obstruction. The garage is detached from the house and remains locked and inaccessible to residents. Laundry units are located inside the garage.

INFECTION CONTROL: During today’s visit, the LPA spoke with the staff 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. The 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. 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.

No deficiencies were observed at this time. Exit interview conducted with the staff. 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: 08/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

LIC809 (FAS) - (06/04)

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