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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609920
Report Date: 06/16/2020
Date Signed: 06/16/2020 11:14:50 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE. SUITE 200
GOLETA, CA 93117
FACILITY NAME:BASSETT ASSISTED LIVINGFACILITY NUMBER:
197609920
ADMINISTRATOR:TAVITIAN, HRIPSIMEFACILITY TYPE:
740
ADDRESS:16011 BASSETT STTELEPHONE:
(818) 442-5702
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY:6CENSUS: 6DATE:
06/16/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:34 AM
MET WITH:Anna BogdanyanTIME COMPLETED:
11:12 AM
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Licensing Program Analyst (LPA) Kelly Dulek conducted a pre-licensing visit at 9:34am with Licensee representative Anna Bogdanyan. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s pre-licensing visit was conducted virtually via FaceTime. The residence is located at 16011 Bassett Street, Van Nuys, CA 91406.

A virtual physical plant tour inside and out was conducted with Licensee representative Anna Bogdanyan. The facility has seven (7) total bedrooms - six (6) private rooms for resident use and one (1) bedroom for live-in staff. All rooms are set up with beds, night stands, lamps, dressers, chairs and closet space; lighting was adequate. There are (4) total bathrooms - three (3) for resident use and one (1) for staff use. All restrooms are equipped with non-skid mats, shower chair and grab bars. Common areas were clean, as well as walls, ceilings, and floors. There is a television and activity supplies available for residents in the living room and furnishings were clean and in good repair. Resident and staff records and medications are stored in a locked cabinet. First aid supplies were complete, including a current version of a first aid manual.

A seven (7) day supply of non-perishable and two (2) day supply of perishable foods was observed. All equipment for storage, preparation, and service of food as well as dishes were clean and in good repair. Appliances in the kitchen were clean and functional. Knives and sharp objects are stored in a locked drawer. Cleaning supplies are stored locked under the kitchen sink. The facility has a laundry room, where laundry supplies and additional chemicals are stored in a locked cabinet. The supply of extra bed and bath linens was in good condition and stored in the hallway closet. Personal hygiene products are stored in resident rooms. There is a functioning telephone on the premises.

Alarms on all exterior doors were properly functioning. The facility smoke alarm/carbon monoxide system was hard wired and tested as functional at 9:54am. Fire extinguisher was fully charged and purchased on 3/12/2020. REPORT CONTINUED ON LIC 809-C

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2020
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, 6500 HOLLISTER AVE. SUITE 200
GOLETA, CA 93117
FACILITY NAME: BASSETT ASSISTED LIVING
FACILITY NUMBER: 197609920
VISIT DATE: 06/16/2020
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Emergency exit plans/sketch are posted by the front door and all required Licensing postings were posted, as well as emergency telephone numbers and evacuation procedures. There is an outdoor patio with furniture available for residents. Gates appeared to be self-latching and all outdoor passageways were free from obstruction at the time of the video visit. There are no bodies of water or dangerous weapons on the premises.

An ambulatory only fire clearance was approved on January 17, 2020. LPA Dulek discussed working on a non-ambulatory fire clearance with licensee representative, as there are existing non-ambulatory residents in the house. Licensee representative agreed to discuss non-ambulatory fire clearance requirements with the facility's consultant. LPA Dulek will follow up with licensee representative to determine the plan to address fire clearance concerns.

Pre-licensing checklist reviewed and exit interview conducted. No Component III was requested by CAB. Report was emailed to licensee representative for signature.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2020
LIC809 (FAS) - (06/04)
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