197609774-6-28-2021-29-AS-SWAR-C4EUQK-20210628154716

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609774
Report Date: 06/28/2021
Date Signed: 06/28/2021 03:47:38 PM

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:	ST KATHERINE ASSISTED LIVING		FACILITY NUMBER:	197609774
ADMINISTRATOR:	NONA KHACHUNTS		FACILITY TYPE:	740
ADDRESS:	6862 KATHERINE AVENUE		TELEPHONE:	(818) 422-0245
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY:	6	CENSUS: 5	DATE:	06/28/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Nona Khachunts, Administrator		TIME COMPLETED:	01:00 PM

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Licensing Program Analysts (LPAs) Salia Walker and Brian Balisi arrived at the facility unannounced to conduct a required annual visit with a specific emphasis on infection control practices and procedures at 11:00 a.m. The LPAs met with Administrator Nona Khachunts at 11:20 a.m. and explained the reason for the visit.

Between 11:00 a.m. and 01:00 p.m. LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards.

KITCHEN: Knives are stored and locked in kitchen cabinet. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Hot water measured at 110.1 Fahrenheit at 11:23 a.m.
BEDROOMS: The LPAs observed the resident bedrooms which were furnished with clean linens, appropriate furnishings, and sufficient lighting.
RESTROOMS: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPAs advised the Administrator to ensure that bathrooms were stocked with paper towels and hand-washing signs. Restroom one (1) hot water measured at 112.3 Fahrenheit at 11:29 a.m. Restroom two (2) hot water measured at 110.1 Fahrenheit at 11:33AM.
COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPAs observed the required postings in the hallway.

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SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021

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: ST KATHERINE ASSISTED LIVING	FACILITY NUMBER: 197609774
	VISIT DATE: 06/28/2021

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BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. The garage is attached to the facility but currently not in use by facility. Licensee stated garage is owned by property owner and licensee does not have access to garage. LPAs observed through window, that garage was not in use at this time.

INFECTION CONTROL: During today’s visit, the LPAs spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. LPAs did not observe an adequate supply of Personal Protection Equipment (PPE) and the administrator was advised additional supplies as needed are available through RO. The facility’s cleaning protocol is sufficient, and facility has sufficient disinfectants. 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 does not have a confirmed case of COVID-19 at this time and the LPAs reviewed facility’s policies and procedures as it pertains to infection control.

Exit interview conducted. A copy of the report issued and provided via E-mail.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021

LIC809 (FAS) - (06/04)

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