197609916-3-10-2024-29-AS-MARO-D38QB7-20240310120105

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609916
Report Date: 03/10/2024
Date Signed: 03/10/2024 12:01:47 PM

Document Has Been Signed on 03/10/2024 12:01 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: 4	DATE:	03/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Irene Saroyan		TIME COMPLETED:	12:10 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) Martha Arroyo arrived at the facility unannounced for a required one-year annual inspection today at 9:00AM. The last annual conducted at this facility was on 02/21/2023. When the LPA arrived, there was one (1) staff and four (4) residents present. The LPA met with staff, Anahit Matevosyan and advised them of the visit. Staff then called the Administrator, and at this time, the reason for the visit was explained. The Administrator, Irene Saroyan arrived at 9:25AM. Entrance interview.

At 9:28AM, the LPA along with the Administrator 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.

KITCHEN: The LPA inspected the kitchen/food service area at 9:35AM. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Food labels were inspected and checked for dates and expiration dates and food labels had expiration date clearly marked. The knives and sharps stored in a locked drawer inaccessible to residents in care. Cleaning supplies were also observed locked and inaccessible under the kitchen sink.

COMMON AREAS: At the time of the visit, the living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. At 10:36AM, the smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was observed to be in compliance and newly purchased on 07/13/2023.

Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2024

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: LEO'S ASSISTED LIVING	FACILITY NUMBER: 197609916
	VISIT DATE: 03/10/2024

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 LIC 809...

The LPA observed required postings throughout the common space. There is a working telephone on premises. Working auditory alarms were observed in all exit doors at the time of the visit. Night lights were present in the hallways. The facility has a sufficient amount of emergency food and water which was observed to be in good condition. The LPA observed a sufficient supply of Personal Protection Equipment (PPE). LPAs observed cameras in the common areas, and throughout the exterior perimeter of the facility.

LAUNDRY ROOM: The washer and dryer were observed inaccessible to residents in care. Laundry detergents were observed locked and inaccessible inside the laundry room.

OUTDOOR AREA: The backyard has a covered patio area equipped with furniture for resident use. Emergency exits and passageways were observed free of obstruction. No bodies of water were noted at the time of the visit. The property is gated. LPA observed the gated door to be single action lock.

GARAGE: 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.

BEDROOMS: There are four (4) resident bedrooms. Two (2) bedrooms are single occupancy, and two (2) bedrooms are double occupancy. The LPA observed the resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

RESTROOMS: There are two (2) resident restrooms. The first restroom is located in the main hallway and the second restroom is located in bedroom #4. Restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. Hand washing signs were observed inside the bathrooms. The hot water temperature was measured in both bathrooms; the first bathroom measured 110.3 degrees Fahrenheit at 9:32AM; and the second bathroom measured 110.6 degrees Fahrenheit at 9:46AM.

Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2024

LIC809 (FAS) - (06/04)

Page: 2 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: LEO'S ASSISTED LIVING	FACILITY NUMBER: 197609916
	VISIT DATE: 03/10/2024

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 LIC 809C...

RECORDS: Records review began at 9:51AM; four (4) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. All records were in order.

Six (6) 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 records were complete.

The current Administrator’s file was also reviewed, and it was complete. Administrator’s certificate is active and expires on 05/17/2024.

At the time of the visit, LPA obtained copies of current LIC 500, Client Roster, and Limited Liability Insurance.

The last emergency disaster drill took place on 01/29/2024.

MEDICATIONS: Medications review began at approximately 11:05AM; medications are centrally stored in a locked file cabinet by the hallway. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. PRNs have physicians order on file. Medications are properly documented on the centrally stored medications and destruction record.

Exit interview conducted. No deficiencies cited. Report was reviewed and a copy was issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3