197609559-8-23-2024-29-AS-SURA-D8ET33-20240823142138

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609559
Report Date: 08/23/2024
Date Signed: 08/23/2024 02:22:09 PM

Document Has Been Signed on 08/23/2024 02:22 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 ONE FACILITY FOR THE ELDERLY		FACILITY NUMBER:	197609559
ADMINISTRATOR:	ATOYAN, ARTUR		FACILITY TYPE:	740
ADDRESS:	7907 STANSBURY		TELEPHONE:	(818) 616-2390
CITY:	PANORAMA CITY	STATE: CA	ZIP CODE:	91402
CAPACITY:	6	CENSUS: 5	DATE:	08/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Artur Atoyan		TIME COMPLETED:	02:35 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) Sandra Urena arrived at the facility unannounced to conduct a required annual visit. The LPA met with staff and explained the reason for the visit. The Administrator arrived at the facility shortly thereafter. The LPA and 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 common area to be relatively clean and properly furnished. All required postings were observed. Exits have functioning auditory devices. The fire alarm/ carbon monoxide detectors were tested and functioned properly. Medications and first aid kits are located in a locked hallway closet. 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 118.6 degrees Fahrenheit. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away inside a kitchen cabinet, and a hallway closet. The LPA observed the fire extinguisher to be fully charged and last serviced on 06/02/2024. BEDROOMS: The facility is a single-story residential home with four (4) bedrooms and three (3) bathrooms for resident's use. The LPA observed residents’ bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. Continued on LIC 809-C…

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANO ONE FACILITY FOR THE ELDERLY	FACILITY NUMBER: 197609559
	VISIT DATE: 08/23/2024

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

RESTROOMS: Three restrooms were observed to be relatively clean and sanitary and in operating condition with grab bars and non-skid mats. The sinks had sufficient liquid soap, and paper towels. Water temperature measured at 116.8-degree Fahrenheit.

OUTDOOR SPACE: The LPA observed the back 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.

RECORDS: Records review began at 12:15 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 1:15 p.m.; medications are centrally stored and locked in a cabinet located inside the locked linen closet; 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

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: 08/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2