197609749-5-17-2023-31-AS-TSMH-CRX23X-20230517170305

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609749
Report Date: 05/17/2023
Date Signed: 05/17/2023 05:03:12 PM

Document Has Been Signed on 05/17/2023 05:03 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:	ENCINO GARDENS		FACILITY NUMBER:	197609749
ADMINISTRATOR:	ARUTUNYAN, ALEX		FACILITY TYPE:	740
ADDRESS:	4930 NOELINE AVE		TELEPHONE:	(818) 983-5598
CITY:	ENCINO	STATE: CA	ZIP CODE:	91436
CAPACITY:	6	CENSUS: 6	DATE:	05/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:07 PM
MET WITH:	Anamit Grigoryan		TIME COMPLETED:	05:10 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	At 1:05 pm Licensing Program Analyst (LPA), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility. LPA was greeted by facility staff and disclosed the purpose of the visit. LPA Smith’s temperature was taken upon entry and the administrator was contacted. LPA Smith spoke to the administrator and the administrator revealed is unable to come to the facility due to personal issues and authorized facility staff to sign. LPA conducted a tour of the physical plant at approximately 1:18 pm to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Common areas were observed for the ability to safely serve the needs residents. These included the kitchen, living room/dining combination, family room. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to be furnished appropriately with adequate seating for residents. LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the six (6) residents currently residing there. Two (2) days of perishable food 7 days non-perishable food observed. The freezer is stocked with meats and frozen vegetables. The resident medications are stored and locked in upper kitchen cabinet. Sharps are locked in upper kitchen cabinet next to sink. Both medications and sharps observed to be inaccessible to residents. Toxin are locked under kitchen sink cabinet; observed to be locked an inaccessible to residents. The facility has a total of six (6) bedrooms and four (4) bathrooms. The resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed a supply of linens in hall closet.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ENCINO GARDENS	FACILITY NUMBER: 197609749
	VISIT DATE: 05/17/2023

NARRATIVE

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(Cont.from 809)

Each bathroom has posted “wash your hands” signs and the following items available: hand soap, paper

towels, and trash cans. The hot water temperature was measured for the four (4) bathrooms to ensure it is
within the required range for residents’ comfort and safety. The water temperature range was between 112.5, 114.3, 112.9- and 115.2-degrees Fahrenheit.

There two (2) fire extinguishers: One in kitchen and one in hallway, both observed to be charged. Smoke detectors/carbon monoxide detector were tested and operable at time of visit.

Backyard has the following: small patio table with chairs. Patio furniture observed to be in good condition.

Garage: No Garage at the facility.

There is pool in the back yard which was observed to be locked inaccessible to residents.

At approximately 1:45 pm, LPA reviewed files for the six (6) residing residents. Resident files included physicians’ assessment, needs and services appraisals. Staff files reviewed for two (2) staff. Staff files had medication training's, and appropriate DSP training's. First aid/AED/CPR for 1 out of 2 files expired or missing.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/17/2023 05:03 PM - It Cannot Be Edited

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: ENCINO GARDENS	FACILITY NUMBER: 197609749
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on (record review, the licensee did not comply with the section cited above in 1 out of 2 staff files have expired or missing CPR/First aid certificates which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/19/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator will ensure staff have the required training and will submit proof of current first aid/CPR for all staff.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC809 (FAS) - (06/04)

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