197609860-9-16-2022-31-AS-ERIS-CJBSXK-20220916141603

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609860
Report Date: 09/16/2022
Date Signed: 09/16/2022 02:16:20 PM

Document Has Been Signed on 09/16/2022 02:16 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:	AMAZING SENIOR CARE, INC		FACILITY NUMBER:	197609860
ADMINISTRATOR:	ANNA PETROSYAN		FACILITY TYPE:	740
ADDRESS:	16938 CITRONIA STREET		TELEPHONE:	(818) 853-6695
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91343
CAPACITY:	6	CENSUS: 6	DATE:	09/16/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Yelena Aladadyan		TIME COMPLETED:	02:30 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Evelin Rios and Michael Cava conducted an Annual Required visit and inspection of the facility. LPAs were granted access by staff Armen Hovhannisyan and the administrator, Yelena Aladadyan met us shortly after and LPAs explained the reason for the visit.

At 11:40am, with the assistance of staff, LPAs took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms and carbon monoxide detectors are dual. They are hardwired and interconnected. The fire extinguisher is located by the dinning area, next to the kitchen. The charge date is 1/28/2022.

Kitchen: The kitchen appliances and fixtures were functional. LPAs 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 one of the cabinets in the dinning area.

Bedrooms: There were four (4) bedrooms designated for residents' use. All four bedrooms, in use by residents were properly furnished with appropriate beddings and linens with sufficient lighting.

Bathrooms: There are two (2) bathrooms designated for residents' use. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 124 degrees Fahrenheit.

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.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMAZING SENIOR CARE, INC	FACILITY NUMBER: 197609860
	VISIT DATE: 09/16/2022

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Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. LPAs observed that a swimming pool in the backyard of the facility has two open unlocked self-latching gates making the pool accessible to persons in care. Swimming pool has a five foot fence installed around its parameters. The laundry area and detergents are located by the kitchen. Cleaning supplies also stored in the laundry area were kept locked and inaccessible to the residents.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records were review for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit.

Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 09/16/2022 02:16 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: AMAZING SENIOR CARE, INC	FACILITY NUMBER: 197609860
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87307(e)

This requirement is not met as evidenced by: Personal Accommodations and Services (e) Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools, or similar bodies of water, when not in active use by residents, through fencing, covering or other means.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in two out of two gates were obeserved to be unlocked by LPAs and caregiver which poses an immediate health, safety or personal rights risk to persons in care. An immediate civil penalty of $500 assessed for this violation.
	POC Due Date: 09/16/2022
	Plan of Correction
1 2 3 4	LPA observed caregiver install padlock on gate. No further action needed.

Type A

Section Cited

CCR

87303(e)(2)

This requirement is not met as evidenced by: (e)Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation, the licensee did not comply with the section cited above in one out of two bathrooms water temperture was measured at 124 degress F which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/16/2022
	Plan of Correction
1 2 3 4	As POC staff adjusted water temperture to 105-120 degress F. No further action needed.

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: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

LIC809 (FAS) - (06/04)

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