197609916-2-21-2023-29-AS-BBAI-CPA2DC-20230221161808

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609916
Report Date: 02/21/2023
Date Signed: 02/21/2023 04:18:13 PM

Document Has Been Signed on 02/21/2023 04:18 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:	IRENE SAROYAN		FACILITY TYPE:	740
ADDRESS:	15932 VOSE STREET		TELEPHONE:	(818) 510-0141
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91406
CAPACITY:	6	CENSUS: 3	DATE:	02/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Irene Saroyan - Administrator		TIME COMPLETED:	04:00 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 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 Irene Saroyanand 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. At approximately 1pm, 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 1:15pm, LPA observed 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. Bedrooms: There were (4) bedrooms total. All bedrooms for clients use were properly furnished and had appropriate bedding and linens. At approximately 1:30pm, LPA observed (1) resident on their laptop in the shaded patio area. Bathrooms: There were (3) bathrooms designated for clients' use. All bathrooms were clean, properly supplied and had functional fixtures. Hot water temperature was measured between 109 - 112 degrees Fahrenheit.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LEO'S ASSISTED LIVING	FACILITY NUMBER: 197609916
	VISIT DATE: 02/21/2023

NARRATIVE

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Continued 809-C

Common Areas: These included the living rooms and dining areas. The common areas were properly furnished and appeared to be relatively clean at this time. There is a hallway closet located near room #1 and LPA observed fresh linen and PPE supplies at this time. Medication is stored in a file cabinet in hallway located after the bathroom. LPA observed cabinet to be inaccessible to residents in care at this time.

Surrounding Grounds: There is a shaded patio in the courtyard of the facility. LPA observed shaded patio furniture appropriate for outdoor use and plenty of room for outdoor activities. LPA did not observe any obstructions to emergency exits at this time. There is a storage shed located in the rear of the facility. LPA observed it to store medical supplies, PPE and other items for facility use. Storage shed was observed locked and inaccessible to residents in care at this time. There is a detached garage located on the property. LPA observed garage being used as a staff office. Office was inaccessible to residents in care at this time. Facility is surrounded by a metal gate. LPA observed the gated door to be single action lock.

The LPA spoke with Irene 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 one of the private bedrooms 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.

Exit interview conducted and report issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023

LIC809 (FAS) - (06/04)

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