197609651-1-19-2024-29-AS-SURA-CZN39T-20240119170336

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609651
Report Date: 01/19/2024
Date Signed: 01/19/2024 05:04:16 PM

Document Has Been Signed on 01/19/2024 05:04 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	VILLA CATHERINE SENIOR CARE FACILITY		FACILITY NUMBER:	197609651
ADMINISTRATOR:	VIKTORYA HAYRAPETYAN		FACILITY TYPE:	740
ADDRESS:	7001 VAN NOORD AVE		TELEPHONE:	(818) 279-4309
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY:	6	CENSUS: 3	DATE:	01/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:18 PM
MET WITH:	Ruzanna Sukiassyan		TIME COMPLETED:	04:09 PM

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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual inspection visit. The LPA spoke with the staff at arrival and introduced myself. Staff called the Administrator, and the administrator stated that they would arrive at the facility soon. The Administrator, Ruzanna Sukiassyan arrived at the facility shortly thereafter. LPA Urena explained the reason for the visit.

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

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The family room furniture was observed to be in good condition. The LPA observed sharp objects and toxins to be locked away, and inaccessible from residents.

BEDROOMS: The LPA observed three residents’ bedrooms, which were furnished appropriately with clean linens, furnishings and sufficient lighting. Bedrooms #1, #2 and #3 were occupied.

RESTROOMS: Residents’ restrooms are clean, and sanitary and in operating condition with grab bars and non-skid surfaces. Bathrooms are sufficiently stocked with hand liquid soap, and paper towels.

COMMON SPACES: The common areas, walls, flooring and furniture were checked for cleanliness and were in good condition. Required postings were observed in the entryway. Exits had a functioning auditory device. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguishers were fully charged and were last serviced on 11/20/2023. The LPA observed required postings throughout the common space.

Continues on LIC 809C…

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024

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

FACILITY NAME: VILLA CATHERINE SENIOR CARE FACILITY	FACILITY NUMBER: 197609651
	VISIT DATE: 01/19/2024

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OUTDOOR AREA: The facility has a pool, which is gated, and was inaccessible to residents at the time of the visit. The LPA observed the backyard to be free of clutter and debris and observed outdoor patio/furniture for residents’ use. The front outdoor area has a water fountain, and at the time of the visit, the water fountain did not have water. The washer and dryer are located outside and were observed to be behind a gate. There were no toxins or detergents observed in the area.

RECORDS: Records review began at 1:44 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 2:30 p.m.; medications are centrally stored and locked in a cabinet in the kitchen area; 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 reviewed the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster

No deficiencies cited at this time. Exit interview conducted. 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: 01/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024

LIC809 (FAS) - (06/04)

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