197609788-7-12-2023-31-AS-MAGN-CTP2A4-20230712171256

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609788
Report Date: 07/12/2023
Date Signed: 07/12/2023 05:13:08 PM

Document Has Been Signed on 07/12/2023 05:13 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	NORTHRIDGE GARDENS BOARD & CARE, INC.		FACILITY NUMBER:	197609788
ADMINISTRATOR:	KHACHATUROVA, GAYANE		FACILITY TYPE:	740
ADDRESS:	18915 LIEDAN ST		TELEPHONE:	(818) 917-5104
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY:	6	CENSUS: 5	DATE:	07/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Gayane Khachaturova-Administrator		TIME COMPLETED:	05:30 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 7/12/23 Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with the administrator, Gayane Khachaturova and staff Narine Sahakyan and Gayane Arakelyan. They were advised of the reason for the visit. At 9:30 am, with the assistance of Administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms and carbon monoxide detectors are dual. Smoke alarms are hardwired and interconnected. The fire extinguisher is located in the kitchen.It was purchased on 5/8/23. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in a closet by the kitchen. Bedrooms: There were (5) bedrooms designated for residents' use. All five rooms are for private use. All rooms were properly furnished with appropriate beddings and linens with sufficient lighting. There is also a sufficient supply of linen and towels stored in the linen closet. Bathrooms: There are two (2) bathrooms designated for residents' use. One (1) bathroom is attached to a private room. All the bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured and it ranged between 110-117 degrees Fahrenheit. LPA observed a bottle of Colrox cleaning solution under bathroom cabinet and was accessible to residents in the bathrooms. Administrator immediately took the bottle and stored away from residents. Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. Garage/Storage Room: LPA observed garage/ storage room door class is broken and unlocked. Upon entrance LPA observed the laundry area, and cleaning solutions are on the floor and accessible to residents. LPA advised Administrator of the immediate health and safety hazard of this area. Administrator immediately started to fix the broken door and lock the room. Temperature:of facility wall thermostat was set at 76.0°F and observed to be within the required range. (Continue on 809C)

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023

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 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: NORTHRIDGE GARDENS BOARD & CARE, INC.	FACILITY NUMBER: 197609788
	VISIT DATE: 07/12/2023

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

During the annual inspection, LPA observed the following deficiencies:

1) Clorox spray bottle in the cabinet bathroom accessible to resident.
2) Licensee is not complying with medication log. Medication sheet is empty and staff don't record type, date and time of medication been taken.
3) Garage/Storage door is broken and unlock. The storage are has cleaning solutions accessible to residents.

Deficiencies are cited on LIC 809D

Exit interview conducted, appeal rights, and copy of the report given.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 07/12/2023 05:13 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
N LA & CEN COA AC/SC, 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: 07/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

This requirement is not met as evidenced by: 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.
	Deficient Practice Statement
1 2 3 4	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 one bottle of CLOROX Sray cleaner under the unlocked sink in the bathroom, which poses/posed a potential health, safety or personal rights risk to persons in care. Also, LPA observed unlocked storage room with cleaning solutions accessable to residents.
	POC Due Date: 07/13/2023
	Plan of Correction
1 2 3 4	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.

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: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 07/12/2023 05:13 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
N LA & CEN COA AC/SC, 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: 07/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(d)(3)

This requirement is not met as evidenced by: 8746(d)(3) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided all of the following requirements are met: The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.
	Deficient Practice Statement
1 2 3 4	Based on observation,interview,record review, the licensee did not comply with the section cited above regulation. staff do not record the type, dose, and time of residents medication been taking on the medication sheet.
	POC Due Date: 07/19/2023
	Plan of Correction
1 2 3 4	Lincesee will adminster training to adress this section of regulation. Proof of training will be submitted to the LPA.

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: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4