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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609891
Report Date: 11/28/2022
Date Signed: 11/28/2022 12:19:25 PM


Document Has Been Signed on 11/28/2022 12:19 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:ANGELES ASSISTED LIVINGFACILITY NUMBER:
197609891
ADMINISTRATOR:ASATRYAN, YULIYAFACILITY TYPE:
740
ADDRESS:15942 BAHAMA STREETTELEPHONE:
(818) 891-4183
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 6DATE:
11/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Yuliya AsatryanTIME COMPLETED:
12:35 PM
NARRATIVE
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On 11/28/22, Licensing Program Analyst (LPA) Melissa Ruiz arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA was greeted by two staff members who were not wearing masks. LPA prompted staff to wear masks. LPA observed covid-19 signage, hand sanitizer, and covid-19 signage posted outside. The purpose of the visit was explained, and an entrance interview was conducted.

LPA initiated a physical plant tour. Facility is a Residential Care Facility for the Elderly which was licensed for six (6) non-ambulatory residents. Facility has five bedrooms, three bathrooms, all designated for resident use. Facility has been approved for a hospice waiver for four (4) residents. LPA was able to tour the home and did not observe any immediate health and safety concerns. Sufficient PPE supplies were observed. The fire extinguisher was observed in the kitchen area and has a date of service of 12/9/2020. Smoke detectors and carbon monoxide monitors were observed to be functional. Facility maintains a temperature of 75 degrees Fahrenheit. LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Sharps, cleaning supplies and medications are centrally stored and are kept locked in various kitchen cabinets and drawers. Bedrooms are appropriately furnished and have appropriate lighting. Bathrooms have soap, paper towels and hand washing signs were observed. Extra towels and linens were readily available. There is a clean covered shaded area in the back yard and there are no bodies of water.

Deficiencies issued during today’s visit. Report was signed and delivered by Administrator and an exit interview was conducted.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2022
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 2


Document Has Been Signed on 11/28/2022 12:19 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: ANGELES ASSISTED LIVING
FACILITY NUMBER: 197609891

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/30/2022
Section Cited

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87470(c) Infection Control Requirements shall be developed by the licensee... (1) The Infection Control Plan shall include: (F) Staff shall demonstrate knowledge... appropriate to the job assigned and as evidenced by safe and effective job performance. This requirement is not met as evidenced by
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Based on observation, the licensee did not ensure that staff are wearing mask at all times while at the facility which poses an immediate health, safety and personal rights risk to residents in care.
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Type A
11/30/2022
Section Cited

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Fire Clearance 80020 (a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
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Based on observation and record review, the licensee did not comply with the section cited above in which the fire extinguisher was observed to have a service date of 12/9/2020 which poses an immediate health, safety or personal rights risk to persons in care.
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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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2022
LIC809 (FAS) - (06/04)
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