197609864-10-5-2023-29-AS-BBAI-CWBTKZ-20231005144847

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609864
Report Date: 10/05/2023
Date Signed: 10/05/2023 02:49:53 PM

Document Has Been Signed on 10/05/2023 02:49 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	GRANT SERENITY HOMES OF SF VALLEY, INC		FACILITY NUMBER:	197609864
ADMINISTRATOR:	ADJIAN, MARTIN		FACILITY TYPE:	740
ADDRESS:	6928 PEACH AVE		TELEPHONE:	(818) 425-6797
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91406
CAPACITY:	6	CENSUS: 6	DATE:	10/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Nvard Gevorkian - Licensee		TIME COMPLETED:	03:00 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 Analysts (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit at 9:20am. Upon arrival LPA met with Administrator Ruzanna Sukiassyan and explained the reason for the visit. At approx. 09:50am, 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. Facility is a single-story residence and consists of a total of six (6) bedrooms and one (1) bathroom. During physical plant tour LPAs observed the required postings throughout the facility. At approx. 9:30am, LPA observed resident having breakfast. The kitchen appeared to be clean and the appliances and fixtures functional during the time of visit. LPAs observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects are stored in a cabinet in the kitchen to the right of the stove. No cleaning supplies or toxins are stored under the sink. Laundry room located to the left of the fridge. It was observed to be inaccessible to residents in care at the time of the visit. LPA observed cleaning supplies and other toxins stored in this location. Non-perishable food panty located to the left of the laundry room. It was observed to be inaccessible to residents in care. LPA observed a sufficient supply of extra non-perishable food stored in this location. The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed bathroom to be clean, properly supplied and had functional fixtures. LPA observed bathroom to have grab bars and non-skid mats. The hot water was measured in each bathroom between 110 - 113 degrees Fahrenheit.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

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: GRANT SERENITY HOMES OF SF VALLEY, INC	FACILITY NUMBER: 197609864
	VISIT DATE: 10/05/2023

NARRATIVE

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Continued from 809
LPA observed common areas which, included the living room, office area and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Planned activities and games were on display on a shelf located near bedroom #2. Medications are stored in a locked cabinet and locked fridge near the office area. LPA observed both to be inaccessible to residents in care. There is a dedicated area for the posting of required documents directly by the entry way into the kitchen. The common areas were observed to be properly furnished and relatively clean at the of the visit. LPA observed appropriate signage regarding infection control posted throughout the facility. LPA observed sanitizer readily available in areas with high touch surfaces. Common room furniture was observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detectors were operational at the time of the visit. Fire extinguishers were observed fully charged and last serviced on 12/29/2022. Between 09:50am - 10:40am LPA observed an entertainer singing with all the residents. All exits in the facility have functioning auditory devices and were operational at the time of the visit.
LPA observed the back patio, with a shaded area and appropriate outdoor furniture for resident use. LPA observed a detached garage. Disinfectants, cleaning solutions, incontinent supplies are stored inaccessible to residents in this area. LPA also observed 7 day emergency food supply kept in the garage as well. Storage room in the rear of the garage was observed to store a sufficient amount of PPE. Behind the garage LPA observed (3) buildings for storage. The building closest to the detached garage was observed to store art pieces. The other (2) storage buildings at the rear of the facility stored decorations, medical equipment, other supplies for facility use and extra art pieces. Next to the detached garage LPA observed an empty pool that was gated and inaccessible to residents in care. The outdoor area behind the detached garage is inaccessible to residents in care at this time. There is a gate on the side of the facility designated for an emergency exit. Passageways were free and clear from obstruction. LPA observed shaded seating area with appropriate outdoor furniture in the front of the facility as well.

Records review began at 10:30 am, five (5) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. At approx. 11:30am, Five (5) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were observed to be in order at this time.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

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: GRANT SERENITY HOMES OF SF VALLEY, INC	FACILITY NUMBER: 197609864
	VISIT DATE: 10/05/2023

NARRATIVE

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Continued from 809-C

Medications: Medications review began at approximately 01:00pm. The medications are centrally stored in a locked storage cabinet near the office area. Medications were observed to be properly documented on the centrally stored medications and destruction record.

Infection Control : Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of a communicable disease. The facility has 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 or relocate residents if the facility has a confirmed case of a communicable disease. The facility’s policies and procedures as it pertains to infection control are adequate at this time.

Between 2pm - 2:30pm the LPA interviewed three (3) staff members and attempted to interview five (5) residents.

LPAs obtained the following documents - Census, Staff schedule, Administrator Documents and updated Limited Liability insurance.

Exit interview conducted and a copy of the report provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

LIC809 (FAS) - (06/04)

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