197609829-8-17-2021-29-AS-SWAR-C5Z2X4-20210817174630

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609829
Report Date: 08/17/2021
Date Signed: 08/17/2021 05:47:46 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:	ARARAT BOARD AND CARE		FACILITY NUMBER:	197609829
ADMINISTRATOR:	SARGSYAN, KARINE		FACILITY TYPE:	740
ADDRESS:	6614 TEESDALE AVE		TELEPHONE:	(818) 624-4180
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY:	6	CENSUS: 6	DATE:	08/17/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:08 PM
MET WITH:	Anahit Kirakosyan, Lead Staff		TIME COMPLETED:	05:45 PM

NARRATIVE

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Licensing Program Analyst (LPA) Salia Walker arrived at the facility unannounced to conduct a required Annual visit at 03:08 p.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Lead Staff Anahit Kirakosyan at 03:22 p.m., and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside at 03:22 p.m., to ensure there are no health and safety hazards. At 03:56 p.m., the LPA conducted a resident file review. Upon review of the resident files, The LPA observed one (1) out of six (6) residents did not have a facility file. The Lead Staff advised the LPA Resident #1 (R1) was recently admitted to the facility, and the administrator did not have a facility file ready.

BEDROOMS: The LPA 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 LPA observed sufficient amounts of soap, paper products, and hand-washing signs in each restroom. Restroom one (1) hot water measured 114.6 Fahrenheit at 01:29 p.m. Restroom two (2) hot water measured 105.4 Fahrenheit at 03:50 p.m. Restroom three (3) hot water measured 113.4 Fahrenheit at 03:40 p.m. Restroom four (4) hot water measured 112.6 Fahrenheit at 03:43 p.m.
KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Hot water measured 116.8 Fahrenheit at 03:32 p.m. All knives and cleaning supplies were observed to be properly stored and locked. All knives and sharps are kept in a file cabinet inside administrator’s office next to the Kitchen.

Continue on LIC 809C..

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021

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: ARARAT BOARD AND CARE	FACILITY NUMBER: 197609829
	VISIT DATE: 08/17/2021

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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 LPA did not observe the required postings in the facility. The LPA advised the Lead Staff facility must post Personal Rights, and CDSS PINs for staff and residents in care. At 03:30 p.m., two (2) out of two (2) fire extinguishers were observed did not display a date of service or purchase, which poses an immediate safety and personal rights risk to persons in care.

BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. The facility has two (2) storage sheds located in the backyard containing additional nonperishable and perishable food items. The garage is attached to the facility, but has a different address not associated with the facility.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Lead Staff regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. 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 LPA reviewed facility’s policies and procedures as it pertains to infection control.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided via email.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021

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: ARARAT BOARD AND CARE	FACILITY NUMBER: 197609829
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/17/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87506(a)

(a) Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the administrator did not comply with the section cited above as one resident (R1) out of six (6) residents does not have a facility file which poses potential health and safety risk to residents in care.
	POC Due Date: 08/23/2021
	Plan of Correction
1 2 3 4	The administrator shall submit proof that R1 has a facility file with required records and documentation by 08/23/2021.

Type A

Section Cited

CCR

87203

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the administrator did not comply with the section cited above, as the fire extinguishers did not display date of service, which poses an immediate safety and personal rights risk to persons in care.
	POC Due Date: 08/23/2021
	Plan of Correction
1 2 3 4	The Administrator shall submit proof the fire extinguishers have been serviced or newly purchased by 08/23/2021.

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021

LIC809 (FAS) - (06/04)

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