197609916-3-3-2022-29-AS-BBAI-CC6T9A-20220303133138

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609916
Report Date: 03/03/2022
Date Signed: 03/03/2022 01:49:34 PM

Document Has Been Signed on 03/03/2022 01:49 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:	LEO'S ASSISTED LIVING		FACILITY NUMBER:	197609916
ADMINISTRATOR:	ARMINE ARAKELIAN		FACILITY TYPE:	740
ADDRESS:	15932 VOSE STREET		TELEPHONE:	(818) 510-0141
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91406
CAPACITY:	6	CENSUS: 4	DATE:	03/03/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:54 AM
MET WITH:	Armine Arakelian - Administrator		TIME COMPLETED:	01:30 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) Brian Balisi arrived to this facility today to conduct a One (1) year Required inspection of this facility with emphasis on infection control practices and procedures. LPA met with Armine Arakelia and explained the reason for the visit. LPA inspected facility for fire safety, personal accommodations and services, and food service. All smoke alarms and combined carbon monoxide detectors were tested and function properly at this time. LPA observed two fire extinguishers to be fully charged and is scheduled for service this month. Between 12pm - 1:30pm LPA conducted physical plant tour of the facility with Administrator. All residents' bedrooms were inspected. Common areas, including living room and dining room appeared clean and were properly furnished. At 12:30pm, LPA observed resident eating in dining area and another resident watching television in the living room. The kitchen appeared clean and the appliances and fixtures functional. Refrigerated and frozen foods were stored at proper temperatures. There was a sufficient amount of perishable and non-perishable food at the facility and properly stored in the laundry room in the kitchen. Sharp objects were observed in the locked top drawer to the left of the fridge LPA observed cleaning supplies stored in a locked cabinet under the sink. Personal accommodations in resident bedrooms and bathrooms were observed for safety, privacy, and comfort. Each resident room was inspected and observed with all required furnishings and grab bars and nonskid surfaces in the bathrooms.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

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

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: LEO'S ASSISTED LIVING	FACILITY NUMBER: 197609916
	VISIT DATE: 03/03/2022

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
26
27
28
29
30
31
32

Continued from 809

Entry/exits were free of obstruction. The outdoor areas were observed to be clean and free of hazards supplied with proper furniture for outdoor use. At 12:45pm, LPA observed resident sitting outside in the shaded patio area. The facility does have a gate that blocks entry in the driveway. LPA observed gate to be single action lock and be easily opened from inside the gate in case of emergency.

The LPA spoke with Armine regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. 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 the master bedroom as a single isolation room if the facility has a confirmed case of COVID-19. COVID-19 testing is conducted weekly if anyone shows any symptoms. The facility’s policies and procedures as it pertains to infection control are adequate at this time.

No deficiencies cited. Exit interview conducted. A copy of the report was issued and sent via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2