197609747-7-30-2021-29-AS-SURA-C5ENRD-20210730104122

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609747
Report Date: 07/30/2021
Date Signed: 07/30/2021 10:42:08 AM

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:	AGNES ASSISTED LIVING		FACILITY NUMBER:	197609747
ADMINISTRATOR:	MELIKYAN, NARINE		FACILITY TYPE:	740
ADDRESS:	7846 AGNES AVE		TELEPHONE:	(323) 675-8888
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY:	6	CENSUS: 5	DATE:	07/30/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Svetlana Petrosian		TIME COMPLETED:	11:00 AM

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On 07/30/2021 at 9:00 am, Licensing Program Analyst (LPA) Sandra Urena arrived at the facility, introduced herself and explained the reason for the visit. LPA conducted an unannounced required annual inspection visit. Caregiver communicated with Administrator. Administrator was unable to be present during the inspection. Caregiver is authorized to sign off on the report. Caregiver provided tour of the facility and provided information requested.

INFECTION CONTROL: Upon entry, the facility has a sign in book, thermometer to take temperature and sanitizing gel. Infection Control signage was visible at entrance. Caregiver asked infection control questions before allowing LPA to enter the facility.

At 9:20 am LPA 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: 9:25 am, LPA 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. Emergency food supply is adequate for residents and staff. Medication cabinet is locked, and medication has a seven-day supply.

Outdoor Space: At 9:40 am, LPA observed the Outdoor space. A shaded patio is available for residents to visit with family members. Sliding door to patio area is activated by alarm system when opened. Side gates are unlocked. Gate leading to outdoors is adapted with sound system to alert staff of any elopement.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021

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: AGNES ASSISTED LIVING	FACILITY NUMBER: 197609747
	VISIT DATE: 07/30/2021

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Bedrooms: At 10:00 am, LPA observed the residents’ bedrooms. Bedrooms were furnished appropriately, appropriate furnishings and sufficient lighting.

Bathrooms: At 10:10 am, LPA observed the Residents’ restrooms. Restrooms were clean, shower area was in clean condition with grab bars and non-skid mat available. Paper towels were available for drying hands.

Facility Records: At 10:30 am LPA reviewed staff and residents’ records. All flies are in good order, and meet licensing requirements.

Personal Protection Equipment (PPE): At 11:00 am, 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: 07/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021

LIC809 (FAS) - (06/04)

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