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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609553
Report Date: 08/20/2024
Date Signed: 08/20/2024 01:57:46 PM


Document Has Been Signed on 08/20/2024 01:57 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:ANO TWO FACILITY FOR THE ELDERLYFACILITY NUMBER:
197609553
ADMINISTRATOR:CHAMCHYAN, NEKTARFACILITY TYPE:
740
ADDRESS:7905 STANSBURYTELEPHONE:
(818) 650-8140
CITY:PANORAMA CITYSTATE: CAZIP CODE:
91402
CAPACITY:6CENSUS: 1DATE:
08/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Nektar ChamchyanTIME COMPLETED:
02:25 PM
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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual visit. The LPA met with the Administrators Nektar Chamchyan, and Artur Atoyan and explained the reason for the visit. At the time of the annual inspection, the facility has one resident. However, the resident is currently at a Skilled Nursing Facility (SNF) receiving physical therapy and is expected to be back in a couple of weeks, depending on the progress done at the SNF.

The LPA, along with the Administrator 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.

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 07/02/2024. Exits have functioning auditory devices. The fire alarm/ carbon monoxide detectors were tested and functioned properly. The LPA observed cameras in the common areas, and throughout the exterior perimeter of the facility. Night lights were present in the hallways and passages.

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. Hot water measured at 110.5-degree Fahrenheit. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away inside a kitchen cabinet. Medications are located in a locked cabinet next to the refrigerator.

Continued on LIC 809-C…
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024
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: ANO TWO FACILITY FOR THE ELDERLY
FACILITY NUMBER: 197609553
VISIT DATE: 08/20/2024
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BEDROOMS: The facility is a single-story facility with three (3) bedrooms for resident use and one (1) office. There are two (2) bathrooms, one (1) bathroom is used for staff only and the other one is for residents' use. 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. Hot water measured at 106.1-degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels.
OUTDOOR SPACE: The 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. There are no bodies of water on the premises. Passageways were free and clear from obstruction. The facility has an accessory dwelling unit (ADU) at the back of the facility and is not part of the license. The ADU remains inaccessible to residents. Laundry units are located in a laundry room area, where two washers and two dryers were observed. The laundry room is kept locked with a key.

RECORDS: Records review began at 12:45 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 annual training. All files were in order.

MEDICATIONS: Medications review began at 1:15 p.m.; Medications are located in a locked cabinet next to the refrigerator.; 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 LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC809 (FAS) - (06/04)
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