197609640-10-31-2024-31-AS-PKHN-DAKTX8-20241031150642

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609640
Report Date: 10/31/2024
Date Signed: 10/31/2024 03:07:18 PM

Document Has Been Signed on 10/31/2024 03:07 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	MIRACLE ASSISTED LIVING FACILITY		FACILITY NUMBER:	197609640
ADMINISTRATOR/ DIRECTOR:	GAYANE AGHABEKYAN		FACILITY TYPE:	740
ADDRESS:	20648 LONDELIUS ST		TELEPHONE:	(747) 206-5390
CITY:	WINNETKA	STATE: CA	ZIP CODE:	91306
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	10/31/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Rima Agaronyan-Backup Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:00 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	On 10/31/24 at 9:45am an unannounced annual visit was conducted by Licensing Program Analyst (LPA) Perchui Milena Khurshudyan . Upon arrival, LPA met with the caregiver Susan Sahakyan, who granted access to the facility. LPA explained the reason for the visit. Shortly after the Backup-Administrator, Rima Agaronyan arrived and helped with physical plant tour and staff/residents files. During today's visit, LPA conducted a physical plant walk through, at approximately 10:20am, to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22. The following was observed: Facility is licensed for capacity of six (6) residents, of which six (6) may be Non-Ambulatory and one (1) bedridden. Facility also has a hospice waiver for five (5) residents. There are five (5) bedrooms in the facility of which four (4) bedrooms designated for residents’ use. Bedrooms are appropriately furnished and have appropriate lighting. There are three (3) bathrooms in the facility. LPA observed bathrooms have soap, paper towels and hand washing signs. The hot water temperature measured at 10:45 to be 114°F. Extra towels and linens were readily available. There are grab bars for each toilet and shower, bathrooms have non-skid mats. All trash cans in bathrooms had fitted lids to protect from cross contamination. The facility has alarms on all exit doors. Centrally stored medications are locked in the cabinets located in the office area right side of the entrance. PRN medications have written orders from a physician. The facility serves residents with dementia and facility has trained staff to meet the needs of residents who are diagnosed with dementia. Potentially dangerous items are kept inaccessible to residents in care. Facility has 2 staff for AM shift and 1 awake caregiver for PM shift. Continue on LIC809-C

Nichelle Gillyard	TELEPHONE: (818) 596-4370
Perchui Khurshudyan	TELEPHONE: (818) 439-7073
	DATE: 10/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024

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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MIRACLE ASSISTED LIVING FACILITY	FACILITY NUMBER: 197609640
	VISIT DATE: 10/31/2024

NARRATIVE

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LPA observed the kitchen area, there was sufficient stock of one-week non-perishable foods and two days of perishable foods. Frozen foods are properly wrapped and stored with expiration date labels on them. Food storage and preparation areas are clean and inaccessible to pests. LPA observed knives and sharp objects were stored in a locked drawer inaccessible to residents in care. The kitchen has a working gas stove, microwave, two (2) refrigerators, and freezer. Extra emergency food was properly stored inside the storage cabinet.

The common areas which include dining and living room appeared clean and were properly furnished. Temperature was comfortable it was measured at 11:20am to be 72°F. No obstructions and or tripping hazards throughout the facility found.

The Facility has one (1) fire extinguisher, LPA observed it was last purchased on 9/7/2024. Laundry room is located in the separate locked area next to the patio. LPA observed all chemicals and detergents are kept locked inside the kitchen cabinet, are under supervision, and inaccessible to residents in care. Smoke detectors and carbon monoxide monitors were tested at 11:45am and observed to be functional. LPA observed a clean covered patio and backyard furniture to accommodate six (6) residents. The backyard is properly fenced. Exit areas are free of obstructions and hazards, exit gates were unlocked and easily accessible. LPA checked inside of the locked shed it was used for facility maintenance purposes. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents. The facility has a swimming pool which is properly fenced and locked. There is no garage.

Between 11:15am to 1:00pm, LPA reviewed records and files of six (6) residents and four (4) staff/caregivers. A review of staff and resident records appeared to be complete. Residents' files contain a signed admission agreements and a medical assessment, and all other required documentarians. A review of staff records indicates that all facility staff and who required caregiver background checks have received criminal record clearances, LPA reviewed LIC501s, LIC503s, LIC9052s, and Training and Education certificates. There are no residents with prohibited conditions residing at the facility.

Continue on LIC809C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui Khurshudyan	TELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MIRACLE ASSISTED LIVING FACILITY	FACILITY NUMBER: 197609640
	VISIT DATE: 10/31/2024

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At approximately 1:00pm to 1:35pm LPA observed each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the clients’ doctor. Proper medication dispensing instruction are followed and checked for contamination. All medications are properly labeled and checked for expiration dates.

First-aid has all proper items and is current. New manual is also available.
Facility also provides activities to the residents. LPA observed puzzles, coloring books, crayons, and board games organized and stored inside the living room cabinet.
An emergency exit plan/sketch is posted along the hallway with other posting requirements.

LPA collected LIC500, LIC9020, Copy of the Administrator certificate, The Infection Control, and Certificate of Liability Insurance.

Facility is in compliance with Title 22 Regulations at this time. No citations issued during this visit.

Exit interview conducted and copy of this report signed and delivered to the Administrator.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui Khurshudyan	TELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024

LIC809 (FAS) - (06/04)

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