197609789-4-19-2022-31-AS-TSMH-CDMRBS-20220419125314

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609789
Report Date: 04/19/2022
Date Signed: 04/19/2022 12:53:25 PM

Document Has Been Signed on 04/19/2022 12:53 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:	LAURELGROVE MANOR 2		FACILITY NUMBER:	197609789
ADMINISTRATOR:	AVETIS VARDANYAN		FACILITY TYPE:	735
ADDRESS:	13557 RANGOON ST		TELEPHONE:	(747) 272-3093
CITY:	ARLETA	STATE: CA	ZIP CODE:	91331
CAPACITY: 4		CENSUS: 3	DATE:	04/19/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:36 AM
MET WITH:	Alvard Yervandyan		TIME COMPLETED:	12:53 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

Licensing Program Analyst (LPA) Tihesha “Lynn” Smith conducted an unannounced One (1) Year Required Infection Control visit to this facility. LPA was greeted by administrator. LPA's temperature taken upon entry and Covid temperature on sign in log. LPA disclosed to administrator the purpose of the visit.

LPA conducted a tour of the physical plant at 10:30 am to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

There are hand sanitizing stations all over the facility including signs to wear a mask and other Covid 19 prevention protocol signs were posted on entry door.

The administrator confirmed there are three (3) ambulatory residents residing at the facility. LPA toured the living room and observed adequate seating for the clients. The living area had furnishings and sufficient lighting. The area was clean and well kept.Smoke alarms and carbon monoxide detectors were present and function properly.

The kitchen appeared clean, odorless, and free from debris. LPA reviewed the food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the three (3) clients currently residing there. Two (2) days of perishable fruits, vegetables, milk, and eggs observed. The freezer is stocked with meats, poultry, and frozen vegetables. Emergency food storage in pantry/closet in living room located to the left of the front entry door.

The sharps and cleaning supplies are kept locked in cabinet to the right of the kitchen in the hallway. The client’s medications, records, and staff files, and additional sharps are locked in linen/cabinet locked in hallway to the left of the kitchen

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022

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 2

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: LAURELGROVE MANOR 2	FACILITY NUMBER: 197609789
	VISIT DATE: 04/19/2022

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

(Cont from 809)
First aid located on top of refrigerator. LPA checked first aid kit and the first aid kit has sufficient supplies. Laundry area is located to the right of the kitchen and observed to be clean and functional. An additional supply of hygiene products is locked in cabinet above washer. Laundry detergents are locked in cabinet of above dryer.

A tour of the resident bedrooms, bathrooms, personal accommodations, and common areas observed (all resident bedrooms toured had the required furniture for residents’ comfort and safety). Common areas were observed for the ability to safely serve the needs of residents, including cleanliness, skid materials, locks, grab bars.

Facility maintains a comfortable temperature for residents.
LPA observed a sufficient supply of linens in the hall closet near bedroom #3.
There are (two) 2 bathrooms: One located off the hallway to the left of the kitchen and the other bathroom off the hallway to the right of the kitchen next to laundry room. LPA observed all bathrooms were clean, properly supplied and had functional fixtures. Each bathroom has “wash your hands” sign posted. LPA observed grab bars and non-skid mats in all bathrooms and the following items available: hand soap, paper towels, and trash cans. LPA measured the hot water between the required limit of 105-120 degrees Fahrenheit during time of visit.

Facility grounds were free of hazards. The backyard has outdoor furniture and grassy area for outdoor activities. LPA observed a covered patio, with two sofas, and a dinette table with four (4) chairs observed to be clean and functional. A gazebo with a dining table with seven (7) chairs observed to be clean, functional, and sufficient seating for the clients.

LPA observed a locked shed in backyard use to store yard tools and equipment.

The detached garage which were observed to be locked and used to store surplus PPE and water.

An additional room attached to the garage used as staff break/resting room observed to be clean and free of hazards.

No Deficiencies cited. Exit interview conducted and printed

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2