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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609788
Report Date: 05/26/2022
Date Signed: 05/26/2022 12:34:42 PM

Document Has Been Signed on 05/26/2022 12:34 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:NORTHRIDGE GARDENS BOARD & CARE, INC.FACILITY NUMBER:
197609788
ADMINISTRATOR:KHACHATUROVA, GAYANEFACILITY TYPE:
740
ADDRESS:18915 LIEDAN STTELEPHONE:
(818) 917-5104
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 6CENSUS: 5DATE:
05/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Gayane Khachaturova, AdministratorTIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Shira Stamps met with Administrator Gayane Khachaturova for an unannounced one (1) year Required visit for this facility.

LPA arrived at 10:40am and was greeted by caregiver Angin Tovmasyan. Two (2) residents were observed in the living room watching TV. The rest of the residents were observed to be in their room sleeping, watching TV and/or resting. The Administrator arrived at 10:45am. LPA informed the Administrator of the purpose of the visit. Entrance Interview conducted.

A tour of the physical plant was conducted with Administrator at 10:50am. The facility has five (5) bedrooms and two (2) bathrooms currently occupying five (5) residents.

Infection control: LPA reviewed the facility mitigation plan (approved on 03/12/21) to make sure licensee was following current infection control recommendations. Upon arrival LPA was screened by caregiver Angin and was asked to sign-in. Sanitizer was made available.

Food Inspection
LPA conducted a tour of the kitchen at 10:50am and observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas care clean and inaccessible to pests. LPA observed one knife sitting in the drying rack in the kitchen sink.The Administrator immediately locked the knife in the draw. LPA observed all other knives and sharp object being locked and inaccessible to residents in care.

CONTINUED...
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2022
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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Document Has Been Signed on 05/26/2022 12:34 PM - It Cannot Be Edited


Created By: Shira Stamps On 05/26/2022 at 12:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: NORTHRIDGE GARDENS BOARD & CARE, INC.
FACILITY NUMBER: 197609788

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(f)(1)
87705(f)(1) Care of persons with Dementia The following shall be stored inaccessible to residents with dementia:(1)Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the Administrator did not have a knife locked and made inaccessible to residents in care. LPA observed one sharp knife sitting in the drying rack in the kitchen sink accessible to residents in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2022
Plan of Correction
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The Administrator immediately locked the knife in the draw with the other sharp objects. The Administrator stated they will train staff on how to properly lock sharp objects after use. Proof of training will be submitted to the LPA.
Type B
Section Cited
CCR
87705(f)(2)
87705(f)(2) Care of persons with Dementia Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the Administrator did not have cleaning supplies locked and inaccessible to residents in care. LPA observed two bottles of Awesome cleaner, one can of bug spray, and one bottle of toilet cleaner under the unlocked sink in the bathroom, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2022
Plan of Correction
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The Administrator locked the chemicals during the visit. The Administrator stated she will conduct a training on how to properly store chemicals with all staff. Proof of training will be submitted to the LPA.
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Shira Stamps
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022


LIC809 (FAS) - (06/04)
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