197609639-9-27-2023-29-AS-SURA-CW3KKJ-20230927075822

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609639
Report Date: 09/26/2023
Date Signed: 09/27/2023 07:59:11 AM

Document Has Been Signed on 09/27/2023 07:59 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
WOODLAND HILLS N.ASC, 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: 4	DATE:	09/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Anna Atayan		TIME COMPLETED:	02:30 PM

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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required Annual visit at 10:00 a.m. The LPA met with Administrator Anna Atayan and explained the reason for the visit.

The LPA and the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations.

KITCHEN: 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. The freezer and refrigerator are stocked with a variety of foods, and fresh vegetables and fruits. The emergency food supply is adequate for six residents and two staff. The hot water temperature measured at 120 degrees Fahrenheit. The washer and dryer are located in the kitchen area. Cleaning supplies and disinfectants are kept locked in the garage.

BEDROOMS The facility has five bedrooms. One (1) bedroom is shared, and four (4) bedrooms are single occupancy. The bedrooms were observed to be furnished appropriately with appropriate furnishings, bedding, and sufficient lighting.

COMMON AREAS: At the time of the visit, living room and dining room furniture were observed to be in good condition. The facility maintained a comfortable temperature of 74 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The facility has two (2) fire extinguishers, which were last purchased on 02/11/2023. The LPA observed required postings throughout the common spaces.

Continues 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: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

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

FACILITY NAME: ANA'S RESIDENCE CARE FACILITY	FACILITY NUMBER: 197609639
	VISIT DATE: 09/26/2023

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RESTROOMS: The facility has four (4) bathrooms. The shower areas were observed to be 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. The hot water temperature measured at 118 degrees Fahrenheit.

OUTDOOR AREA: The backyard was observed to be free of clutter and debris. There is a shaded area for residents and outdoor furniture for family members to meet. No bodies of water noted.

RECORDS: Records review began at 12:30 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 1:45 p.m. medications are centrally stored and locked in a cabinet in the kitchen. 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 obtained the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster
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 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: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC809 (FAS) - (06/04)

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