197609553-8-23-2023-29-AS-EPEI-CUYTWU-20230823150607

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609553
Report Date: 08/23/2023
Date Signed: 08/23/2023 03:06:23 PM

Document Has Been Signed on 08/23/2023 03:06 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: 2	DATE:	08/23/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:55 PM
MET WITH:	Nektar Chamchyan, Administrator		TIME COMPLETED:	03:20 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 1:55 p.m., the LPA met with the Administrator and explained the reason for the visit. At 2:05 p.m., 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. 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 2:28 p.m., 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 and first aid kits are located in a locked cabinet near the kitchen. BEDROOMS: The facility is a single-story residential home 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 resident 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. At 2:10 p.m., hot water measured at 106.1-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: 08/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: 08/23/2023

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
26
27
28
29
30
31
32

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 07/18/2023. Signs are posted throughout facility to promote handwashing, and cough/sneeze etiquette. Exits have functioning auditory devices. At 2:14 p.m., 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.

OUTDOOR SPACE: At 2:15 p.m., 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 inside the ADU.

Between 2:19 p.m. and 2:27 p.m., the LPA conducted interviews two (2) residents and one (1) staff.

Due to time constraints the LPA will return to complete the annual at a later date.

Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2