<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609687
Report Date: 07/11/2023
Date Signed: 07/11/2023 03:13:21 PM

Document Has Been Signed on 07/11/2023 03:13 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:DEMPSEY GARDEN INCFACILITY NUMBER:
197609687
ADMINISTRATOR:HAKOBYAN, MARINEFACILITY TYPE:
735
ADDRESS:8315 DEMPSEY AVETELEPHONE:
(747) 344-8070
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 4CENSUS: 4DATE:
07/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Marine HakobyanTIME COMPLETED:
03:12 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 7/11/2023 Licensing Program Analyst (LPA) Melissa Ruiz arrived at the facility listed above to conduct an unannounced annual inspection. Upon entry, LPA observed appropriate covid-19 postings along the entrance wall by the front door. LPA was greeted by staff #1 (S1) and granted access. LPA explained the reason for the visit and LPA later met with the Administrator Armine Melkonyan.

LPA and the Administrator toured the physical plant of the facility, and the following was observed:

Bedrooms: LPA inspected four out of four bedrooms which three (3) are for client use. Bedrooms are for private use. LPA observed each resident bedroom to be properly furnished with one bed, appropriate nightstand, chair, bedding and with sufficient lighting and storage.

Bathrooms: The facility has three (3) bathrooms one (1) is designated for staff use. LPA observed the bathrooms to be clean and properly supplied with toilet paper, paper towels, hand soap, and trash bins with lids. In the hallway LPA observed linen closets used to store extra PPE and a first aid kit.

Laundry/Garage: Laundry room is kept locked and is in the garage. Detergents are kept locked in a cabinet under the laundry sink. Garage is not accessible from inside the facility. In the garage LPA observed a second fridge with extra food stored for residents, a deep freezer, and PPE supplies. Garage is also used to store extra supplies for residents.

(Continued on LIC809-C)
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: DEMPSEY GARDEN INC
FACILITY NUMBER: 197609687
VISIT DATE: 07/11/2023
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
26
27
28
29
30
31
32
Living room: The living room and common areas were clean and properly furnished. Fireplace is not in use and secured with a screen. LPA observed Administrator test a dual smoke and carbon monoxide detector. Detector is hardwired and interconnected to other detectors located throughout the facility. Detectors were observed to be functioning properly. There is a fire door leading to the bedrooms that automatically closed during the test.

Kitchen/ Dinning area: The kitchen was observed to be clean and clear of clutter. Appliances and fixtures were functioning properly. LPA observed cleaning products kept locked under the kitchen sink. LPA observed knives and sharps locked in drawer. LPA observed a sufficient amount of 2- day perishable and 7-day non-perishable food at the facility; properly stored. LPA observed one (1) fire extinguishers fully charged with a last serviced date of 03/06/2023. Dining area had appropriate table and chairs to sit the capacity of the facility.

Medications: Centrally stored medications are maintained in a locked designated cabinet located in the kitchen. Medications were observed locked. At 2:23 p.m. LPA and Administrator reviewed and counted residents' medications. Refills are either done automatically or ordered by the physician. Medication Records were reviewed for proper documentation. Medication records are maintained manually.
At approximately 10:45 a.m. LPA conducted and/or attempted interviews with two (2) out of two (2) residents, the administrator, and S1 who was present at the facility.

Resident/Staff Records: At approximately 11:10 a.m. four (4) out four (4) resident records and (2) staff records were reviewed to ensure compliance.

Surrounding Grounds: There is a covered patio that offers shade with appropriate furniture for residents to use. LPA observed a locked shed being used for storage. Side gate was checked to insure it was clear of obstruction.

No deficiencies observed. Exit Interview conducted. Copy of report provided.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2