<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609566
Report Date: 05/12/2022
Date Signed: 05/12/2022 10:30:00 AM


Document Has Been Signed on 05/12/2022 10:30 AM - 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., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:ANGEL TOUCH ELDERLY CAREFACILITY NUMBER:
197609566
ADMINISTRATOR:ADZEMIAN, VARDANFACILITY TYPE:
740
ADDRESS:20601 MAYALL STTELEPHONE:
(818) 532-2867
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:6CENSUS: 3DATE:
05/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Joseph Aguilos TIME COMPLETED:
10:35 AM
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
On 05/12/22 at 9:15 a.m Licensing Program Analyst (LPA) Joscelyn Martinez arrived at the facility to
conducted an unannounced annual inspection. Upon arrival LPA was greeted by staff and LPA’s temperature
was taken. LPA Martinez called the Administrator and the purpose of the visit was explained. Administrator designated Staff Joseph Aguilos to sign the report on his behalf.

A physical tour of the facility was conducted at 9:30 a.m and the following was observed:
Infection Control: Covid-19 infection control signage were observed outside of the facility. Proper signage was also observed inside in the common areas. Facility has sufficient PPE supplies for more than 30 days. Food Inspection/Kitchen: LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Kitchen, food storage, and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers in the kitchen. Sharps and medications are centrally stored in a locked area. Smoke/carbon monoxide detectors are located throughout the facility and are hardwired. Smoke and carbon monoxide detectors were tested at 9:52 a.m appear to be functional. Fire extinguisher has a purchase date of 04/28/2022. Common Areas: All common areas were observed to be clean and properly furnished. Facility maintains a comfortable temperature of 75.0 F. Resident Rooms: Facility has seven (7) bedrooms which of six (6) are designated for resident use. Facility has a live-in staff. All seven (7) bedrooms were toured and appear to be clean and properly furnished. LPA observed additional bedding and linens sufficient for all of the residents. All rooms have adequate lighting. Bathrooms: There are three (3) bathrooms in the facility of which two (2) are designated for residents’ use. LPA observed all bathrooms to be clean and free of any hazards. Grab bars and non-skid mats were observed. The hot water was tested and measured at 117.5 F.

(Continue on 809-C)
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANGEL TOUCH ELDERLY CARE
FACILITY NUMBER: 197609566
VISIT DATE: 05/12/2022
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
 Garage: There is an attached garage that is used for additional storage and laundry area. Chemicals are stored inside the garage. This area is inaccessible to residents. Outside Area: LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water.

No deficiency cited. Exit interview conducted. Report signed and delivered.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2