197609920-5-20-2021-29-AS-BBAI-C37UJC-20210520153719

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609920
Report Date: 05/20/2021
Date Signed: 05/20/2021 03:38:05 PM

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:	BASSETT ASSISTED LIVING		FACILITY NUMBER:	197609920
ADMINISTRATOR:	TAVITIAN, HRIPSIME		FACILITY TYPE:	740
ADDRESS:	16011 BASSETT ST		TELEPHONE:	(818) 442-5702
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91406
CAPACITY:	6	CENSUS: 5	DATE:	05/20/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Emma Arutiunian House Manager		TIME COMPLETED:	03:30 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 Analysts (LPAs) Brian Balisi and Martha Guzman-Chavez initiated a Required Annual inspection with focus on Infection Control today. LPAs met with Emma Arutiunian and explained the reason for the visit. There are (6) bedrooms for residents and (1) bedroom for staff use only. Between 1:30pm - 3:30pm The physical plant was toured inside and out with Administrator. LPA observed wired smoke and carbon monoxide detectors throughout the facility. (1) fire extinguisher located in the kitchen. All rooms are set up with beds, night stands, comfortable/appropriate chairs, chest of drawers and closet space. Lighting in the rooms appeared adequate at the time of the visit. All rooms have overhead lighting. Bathrooms are equipped with grab bars and non-skid materials. Hot water tested in the bathrooms measured between 113 degrees F. LPA observed an adequate supply of perishable and non-perishable foods in the fridge. Medications were stored in a locked file cabinet by the first bedroom. Sharp objects and knives were stored in a locked drawer to the right of the kitchen sink. LPA observed a sufficient supply of non-perishable foods and dried goods stored in the pantry. Emergency food supply was stored in this location as well. LPA did not observe any cleaning supplies stored in the kitchen. At 1:45pm LPA observed staff cleaning the common areas. The supply of dishes was observed to be adequate at this time. Continued on 809-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021

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: BASSETT ASSISTED LIVING	FACILITY NUMBER: 197609920
	VISIT DATE: 05/20/2021

NARRATIVE

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The common areas were appropriately furnished, and lighting was adequate at the time of the visit.

There is an area in the side of the house with outdoor furniture. This facility shares a lot with Bassett Residential Care #197609923. Exit passageways were clear of hazards and obstructions. LPAs observed storage unit the rear of this facility. LPAs ask Emma to open storage unit and LPAs observed medical supplies, furniture and other home items stored in this space.

Between 1:30pm - 03:30pm, LPAs did not observe a sufficient amount of the following: Signs that are posted throughout facility to promote hand washing , cough / sneeze etiquette, and physical distancing and signs that are posted throughout facility to encourage residents to report acute respiratory illness to staff.

Emma also informed LPAs that not all staff have been fit tested for N95 respirators.

LPAs advised Emma to post additional signs throughout the facility and LPAs will provide Emma with information and resources to have all staff fit tested for N95 respirators.

Pursuant to Title 22, Division 6, facility observed to be compliant with regulation. No corrections needed at this time. Exit interview was conducted with house manager and a hard copy was issued via email

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021

LIC809 (FAS) - (06/04)

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