197609829-8-26-2022-29-AS-ASMH-CHNN75-20220826101211

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609829
Report Date: 08/26/2022
Date Signed: 08/26/2022 10:13:01 AM

Document Has Been Signed on 08/26/2022 10:13 AM - 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. #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:	08/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Mariam Panadzhyan		TIME COMPLETED:	10:10 AM

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) Ashley Smith arrived unannounced to conduct a required annual visit. This annual had a specific emphasis on infection control practices. The LPA initially met with staff, whom contacted the Licensee. Licensee representative Mariam Panadzhyan whom arrived shortly after, and the LPA explained the reason for the visit. The LPA, along with staff, toured the facility to ensure there are no health and safety hazards. The LPA spoke with residents during the tour; residents appeared satisfied and voiced no concerns. KITCHEN: Knives are stored inaccessible in the staff room. At 9:10 a.m., the LPA observed accessible chemicals under the kitchen sink. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: There are five rooms total; four resident rooms and one designated staff room. Bedrooms had appropriate furniture, clean linens and sufficient lighting. Rooms were clean and clear of obstructions. RESTROOMS: The four restrooms were clean and sanitary with grab bars and non-skid surfaces. At 9:50 a.m., water temperature measured within the required range.. Restrooms were stocked with soap and paper towels. COMMON SPACES: The facility maintained a temperature of 76 degrees. Medications were kept locked in the staff room. Living room and dining furniture were observed in good condition. Fire extinguisher was purchased August 2022. The backyard and exterior area of the facility had furniture and a covered area for resident use. No obstructions observed in the exterior or interior. No bodies of water noted. Upon entry to the property, the front gate was locked. Staff had to obtain a key to allow the LPA into the property. Whereas one side of the property has an exit with a self-latch lock, it was locked, and a key had to be obtained in order to unlock it. The facility does not have a fire clearance that allows for the locking of exterior doors. The LPA explained that it was a zero-tolerance violation and needed to be corrected within twenty-four hours.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

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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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: 08/26/2022

NARRATIVE

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INFECTION CONTROL: There is a central entry point for screening and temperature checks. The LPA reminded the licensee representative to continue screening residents and incoming volunteers. Appropriate infection control signage was observed throughout the facility. Staff were not wearing appropriate face coverings upon entry into the location, yet wore masks once the LPA explained the protocol. The facility’s cleaning protocol is sufficient. There is record of staff and resident vaccinations. The facility can designate a room to isolate persons if there is a confirmed case of COVID-19. Staff are up to date regarding guidelines around visitation and vaccine requirements.

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. Civil penalties assessed for zero tolerance violation. Failure to correct the deficiencies may result in civil penalties.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/26/2022 10:13 AM - 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
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: 08/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) 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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as accessible chemicals were observed in the cabinet under the sink, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/26/2022
	Plan of Correction
1 2 3 4	The Administrator agreed to do the following: 1. Remove the cleaning supplies and lock them away. This was done during today's visit. Plan of Correction met.

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 licensee did not comply with the section cited above, as the exterior gate and latched gate were locked, which did not allow residents to egress the facility without a key, which poses an immediate safety and personal rights risk to persons in care.
	POC Due Date: 08/27/2022
	Plan of Correction
1 2 3 4	1. Locking mechanism needs to be removed from the single-latch gate, and the lock on the exterior gate will need to be changed to a single latch lock within the next 24 hours. Civil penalty assessed in the amount of $500 for the zero tolerance violation.

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: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 08/26/2022 10:13 AM - 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
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: 08/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468.1(a)(2)

Personal Rights of Residents in all Facilities

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as staff were observed not wearing appropriate face coverings and did not ask COVID-19 screening questions upon the LPA's arrival, which poses a potential personal rights risk to persons in care.
	POC Due Date: 08/31/2022
	Plan of Correction
1 2 3 4	1. The Administrator agreed to do the following: Conduct a staff training, communicating the protocol around face coverings and screening for COVID-19. Submit sign-in sheet to the Department no later than 8/31/2022.

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

LIC809 (FAS) - (06/04)

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