197609877-1-8-2024-31-AS-TSMH-CZAV73-20240108151027

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609877
Report Date: 01/08/2024
Date Signed: 01/08/2024 03:10:39 PM

Document Has Been Signed on 01/08/2024 03:10 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	IN HOME CARE CENTER		FACILITY NUMBER:	197609877
ADMINISTRATOR:	DOVLATYAN, KRISTINE		FACILITY TYPE:	740
ADDRESS:	9023 GAVIOTA AVE		TELEPHONE:	(747) 998-7577
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY:	6	CENSUS: 5	DATE:	01/08/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Kristine Dovlatyan		TIME COMPLETED:	03:12 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) Tihesha Smith conducted an unannounced Required 1-year inspection at this facility at approximately 10:45 am. LPA disclosed to staff the purpose of the visit and the administrator was contacted and arrived later LPA conducted a tour of the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Common areas were observed for the ability to safely serve the needs residents. These included the kitchen, dining area and living room. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to be furnished appropriately. LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the five (5) residents currently residing there. Sharps stored in top kitchen drawer, observed to be locked and inaccessible to residents. The resident medications are locked in standalone cabinet. The medications were observed to e inaccessible to residents. There is one (1) fire extinguisher located in living room attached to wall. Fire extinguisher observed to be charged. The facility has three (3) bedrooms and two (2) bathrooms: The resident bedrooms furnished with at least one chair, nightstand, and sufficient lighting for each resident.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2024

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: IN HOME CARE CENTER	FACILITY NUMBER: 197609877
	VISIT DATE: 01/08/2024

NARRATIVE

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(cont. from 809)

The bedrooms had appropriate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed a supply of linens stored in laundry room cabinets above washer and dryer.

The hot water temperature was measured for the bathroom to ensure it is within the required range for residents’ comfort and safety. The water temperature range was 115.6 -degrees Fahrenheit.

Surrounding Grounds: Entry/exits were free of obstruction. Sufficient seating for outdoor furniture.

Laundry room is adjacent to kitchen. Appliances observed to be in good repair. Toxins stored in cabinets in laundry area observed to be locked and inaccessible to residents.

Garage: used to store supplies and equipment

At approximately 1:15 pm, LPA Smith reviewed five (5) resident files and five (5) staff files. Resident files included physician’s reports and Centrally stored meds. Staff files included current first aid and administrator license is current and posted.

No deficiencies cited.

Exit interview conducted/Copy of report given

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2024

LIC809 (FAS) - (06/04)

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