197609639-9-9-2022-29-AS-SURA-CJ52RF-20220909173726

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609639
Report Date: 09/09/2022
Date Signed: 09/09/2022 05:38:12 PM

Document Has Been Signed on 09/09/2022 05:38 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:	ANA'S RESIDENCE CARE FACILITY		FACILITY NUMBER:	197609639
ADMINISTRATOR:	ANNA ATAYAN		FACILITY TYPE:	740
ADDRESS:	7747 VAN NOORD AVE		TELEPHONE:	(323) 688-3377
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY:	6	CENSUS: 5	DATE:	09/09/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:16 PM
MET WITH:	Anna Atayan		TIME COMPLETED:	03:05 PM

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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required Annual visit at 1:16 p.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Anna Atayan, and explained the reason for the visit.

INFECTION CONTROL: Upon entry, the facility has a sign in book and sanitizing gel. Infection Control signage was visible at entrance. Temperature was taken by staff, and the LPA was asked to sign in.

The LPA, and the administrator toured the inside and outside of the facility to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

At 1:35 p.m., the LPA and the administrator toured the living room area and common area and found them to be appropriately furnished, cleaned, and in good condition.

Kitchen: At 1:40 p.m., the LPA and the administrator observed the kitchen/dining area. Knives are stored in a locked cabinet drawer. Kitchen appliances were in operable condition. The facility has enough supply of perishable and non-perishable food. Freezer and refrigerator are stocked with a variety of foods, and fresh vegetables and fruits. Emergency food supply is adequate for six residents, and two staff.

Bedrooms: At 1:50 p.m., the LPA, and the administrator observed the residents’ bedrooms. Facility has five bedrooms. One bedroom is shared, and three bedrooms are single occupancy. Bedrooms were furnished appropriately with appropriate furnishings, bedding, and sufficient lighting.

Continues on LIC 809 C...

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANA'S RESIDENCE CARE FACILITY	FACILITY NUMBER: 197609639
	VISIT DATE: 09/09/2022

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Bathrooms: At 1:55 p.m., the LPA inspected the residents’ bathrooms. The facility has four (4) bathrooms. The shower areas were in clean condition with grab bars and non-skid mats available. Soap, and paper towels were available for drying hands. Hand washing signs were displayed.

Outdoor Space: At 2:10 p.m., the LPA observed the backyard of the facility to be free of clutter and debris. There is a shaded area for residents and family members to meet.

The LPA observed 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 facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies were cited at this time. Exit interview conducted. Signatures obtained. A copy of report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022

LIC809 (FAS) - (06/04)

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