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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609829
Report Date: 09/18/2024
Date Signed: 09/18/2024 06:02:07 PM


Document Has Been Signed on 09/18/2024 06:02 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:ARARAT BOARD AND CAREFACILITY NUMBER:
197609829
ADMINISTRATOR:SARGSYAN, KARINEFACILITY TYPE:
740
ADDRESS:6614 TEESDALE AVETELEPHONE:
(818) 624-4180
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY:6CENSUS: 5DATE:
09/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:MARIAM PANADZHYANTIME COMPLETED:
06:15 PM
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Licensing Program Analysts (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 12:40 p.m. Upon arrival, LPA Mosley was greeted by staff and co-administrator and informed them of the visit. The LPA met with Co-Administrator Mariam Panadzhyan and explained the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: The LPA inspected the kitchen/food service area at 12:57 p.m. Knives and sharps were observed in the locked staff room adjacent to the kitchen. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. Nonperishable foods including peanuts, ketchup and mac and cheese in food pantry area were expired dating 04/03/2024; 01/23/2024 and 01/25/2024.The expired food poses a potential health and safety risk to persons in care. Administrator was made aware, and food was immediately removed. The kitchen faucet was measured for hot water temperature, and it measured 115.5 degrees Fahrenheit at 12:57 p.m. There is a washer and dryer on premises in the kitchen area. Laundry detergent was observed in the staff room adjacent to the kitchen.

COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 3:45 p.m., hardwired, smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was observed, fully charged, and purchased on 03/31/2024. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 07/06/2024. Activities were observed in the common areas.

Report Continued on LIC 809C...

SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica MosleyTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ARARAT BOARD AND CARE
FACILITY NUMBER: 197609829
VISIT DATE: 09/18/2024
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Report Continued from LIC 809...

RESTROOMS: There are four (4) total restrooms. Two (2) for resident use, one (1) for staff use which remains locked at all times in the staff room, and one (1) guest half restroom that can also be used by residents if needed. The two (2) resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured; the first resident restroom measured at 107.4 degrees Fahrenheit at 12:54 p.m., the second resident restroom measured at 118.0 degrees Fahrenheit at 12:57 p.m. and the guest half restroom measured 105.6 at 1:17 p.m. All restrooms measuring within the required range.

BEDROOMS: There are 5 (five) total bedrooms in the facility; Four (4) are designated as resident rooms, and one (1) as a locked staff room. Of the four (4) resident rooms two (2) are designated as shared rooms, and two (2) are designated as private resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

BACKYARD/OUTDOOR AREA/ SHEDS: The outdoor area has a storage area which previously housed the washer and dryer and is used as storage for emergency food and PPE supplies. There is a locked shed on the side of the home that stores cleaning supplies and chemicals. The shed is maintained locked at all times. LPA observed an adequate amount of emergency food and water. Cleaning supplies are kept locked and inaccessible to residents in care. The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. LPAs observed one (1) self-latching gate. There were no bodies of water noted at the time of the visit.



Report Continued from LIC 809C...
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica MosleyTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ARARAT BOARD AND CARE
FACILITY NUMBER: 197609829
VISIT DATE: 09/18/2024
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Report Continued from LIC 809C...

MEDICATIONS: Medications review began at approximately 3:47 p.m. The medications are locked in the staff room filing cabinet adjacent to the kitchen. Medications for five (5) clients were reviewed. Medications reviewed were found to be self-administered as prescribed and documented on the centrally stored medication and destruction records.


RECORDS: Resident Records were reviewed beginning at 2:10 p.m. and personnel records at 3:24 p.m. Five (5) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan.


Four (4) personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order.

INTERVIEWS: Two (2) staff interviews were attempted, due to language barriers only one (1) was conducted. Five (5) resident interviews were attempted, three (3) were conducted. One (1) visitor/ family member interview was conducted.

Deficiencies were cited during today’s inspection. Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica MosleyTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/18/2024 06:02 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: ARARAT BOARD AND CARE
FACILITY NUMBER: 197609829

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

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 nonperishable foods including peanuts, ketchup and mac and cheese in food pantry area were expired dating 04/03/2024; 01/23/2024 and 01/25/2024 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2024
Plan of Correction
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Administrator agrees to purchase items to replace the ones that are expired. Adminstrator agrees to check food pantry for lables and send picture proof of items that were pulled from pantry.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica MosleyTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2024
LIC809 (FAS) - (06/04)
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