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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609609
Report Date: 07/22/2023
Date Signed: 07/22/2023 05:06:34 PM

Document Has Been Signed on 07/22/2023 05:06 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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:KDAD INCFACILITY NUMBER:
197609609
ADMINISTRATOR:ADAMYAN, ARMINEFACILITY TYPE:
735
ADDRESS:9500 NATICK AVETELEPHONE:
(818) 326-4433
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 4CENSUS: 4DATE:
07/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Armine AdamyanTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility at approximately 10:35 am. LPA Smith rang doorbell no answer. The administrator was contacted by LPA Smith and arrived later. Upon arrival Administrator greeted LPA and LPA revealed purpose of the visit.

LPA conducted a tour of the physical plant at approximately 11:20 am to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Common areas were observed for the ability to safely serve the needs residents. These included the kitchen, dining room area and living room. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to be furnished appropriately.

LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The
kitchen food supply was observed and sufficient for the four (4) residents currently residing there. Two (2) days of perishable food observed. The freezer is stocked with meats and frozen vegetables. The resident medications are locked in upper cabinet in kitchen and observed to be locked an inaccessible to residents in care. The first aid kit is attached to wall in kitchen near medications. Sharps are stored in medication cabinet and observed to be locked and inaccessible to residents.. The medications were observed to be inaccessible to residents. There is one (1) fire extinguisher attached to wall in dining area. Fire extinguisher observed to be charged.

Laundry room is in hallway near main entrance. The appliances observed to be in good repair. Toxins stored in laundry room cabinet. Toxins observed to be locked and inaccessible to residents.

The facility has a total of five (5) bedrooms and two (2) bathrooms. There are four (4) private bedrooms for residents and one (1) bedroom for staff and one (1) bathroom for residents.
(Cont to 809C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2023
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: KDAD INC
FACILITY NUMBER: 197609609
VISIT DATE: 07/22/2023
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(Cont from 809)

The resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed a supply of linens hall closet near bathroom.
The bathroom has posted “wash your hands” signs and the following items available: hand soap, paper
towels, and trash cans. The hot water temperature was measured for the bathroom to ensure it is
within the required range for residents’ comfort and safety. The water temperature measured:105.0 degrees Fahrenheit.

Garage: No garage designated for facility use

Backyard has the following: Patio with an umbrella observed to have adequate seating. Patio furniture observed to be in good repair.

Smoke detectors/carbon monoxide detector were tested and operable at time of visit.

Facility grounds were free of hazards. There were no immediate health and safety hazard observed during the day of inspection.

At approximately 1:15 pm LPA reviewed all four (4) resident files. Resident files included but not limited to: medical assessments, admission agreements, personal rights, individual program plan, and immunization records. Three random staff files reviewed. Staff records reviewed had the appropriate personal records such as: Clearances, Employee Rights and First aid/CPR. Staff training's such as: Medication administration, rights of medication, administrator training, and certificates stored in separate binder.

No deficiencies cited.

Exit Interview Conducted / A Copy of the Report Issued
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2023
LIC809 (FAS) - (06/04)
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