197609862-7-15-2021-31-AS-JGTN-C4XVK2-20210715162936

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609862
Report Date: 07/15/2021
Date Signed: 07/15/2021 04:29:52 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	EMERALD ESTATE SENIOR CARE, INC		FACILITY NUMBER:	197609862
ADMINISTRATOR:	LYSENKO, OLENA		FACILITY TYPE:	740
ADDRESS:	10401 ENCINO AVE		TELEPHONE:	(747) 300-2232
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	6	CENSUS: 5	DATE:	07/15/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:41 PM
MET WITH:	Harutyun Petoyan - Staff		TIME COMPLETED:	04:30 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) Gary Tan, met staff Harutyun Petoyan for a One (1) Year Required - Infection Control visit for this facility. Administrator Elen Hayrapetyan was called and designated Mr. Petoyan to sign the report. LPA explained the reason for the visit. A tour of the physical plant was conducted at 1:11 PM and the following was noted: There is only one entrance being utilized at the facility, there are required poster posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask upon entrance and during visit. The facility had submitted and approved Mitigation plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area at the front and backyard. The facility has sufficient stock of PPE in the storage room. The facility has five (5) bedrooms and two (2) bathrooms currently occupying five (5) residents. One (1) bedroom is designated for staff use. The facility is fire cleared for six (6) non-ambulatory residents, of which, one may be bedridden in Room #3 or #5, hospice waiver for five (5) residents. The garage is converted into an office with sink and bathroom. The office is inaccessible to residents. (continued on LIC 809-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2021

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: EMERALD ESTATE SENIOR CARE, INC	FACILITY NUMBER: 197609862
	VISIT DATE: 07/15/2021

NARRATIVE

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(continued on LIC 809-C)

Living and dining room furniture were also checked. The living room is neat and clean. The facility maintains a comfortable temperature at 74°F. The smoke detectors are hardwired and interconnected and observed to be operational. There is a carbon monoxide installed at the facility. Fire extinguisher is located in the kitchen and observed to be full and last bought on 09/08/2020.
The backyard of the facility has outdoor furniture, with a covered shaded area for clients. There is no body of water at the facility.
There is no garage at the facility, only gated car ports. Laundry room is located adjacent to the kitchen and the access area going to the office. Laundry detergents, cleaning agents and other toxins are stored in the laundry area. The laundry area was observed to be locked and inaccessible to residents. Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents.

The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit. Clients have sufficient amounts of personal hygiene product which is provided by the licensee.

Staff Room: Staff room was observed to be locked. No medications are observed in the staff room.

The bathroom was checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the toilet and shower. The hot water temperature was measured a range of 114.2°F to 116.7°F. Towels and washcloths are not shared. There was enough clean linen available in stock at the cabinet.

Medications: LPA observed medication are kept in a locked cabinet in the laundry room. There is a complete first aid kit located at the medication cabinet.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2021

LIC809 (FAS) - (06/04)

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