197609920-7-29-2024-29-AS-VCOY-D7MU4N-20240729151524

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609920
Report Date: 07/29/2024
Date Signed: 07/29/2024 03:15:31 PM

Document Has Been Signed on 07/29/2024 03:15 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BASSETT ASSISTED LIVING		FACILITY NUMBER:	197609920
ADMINISTRATOR:	EMMA ARUTIUNIAN		FACILITY TYPE:	740
ADDRESS:	16011 BASSETT ST		TELEPHONE:	(818) 442-5702
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91406
CAPACITY:	6	CENSUS: 5	DATE:	07/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Emma Arutiunian		TIME COMPLETED:	03:30 PM

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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 10:00 a.m. LPA met with facility representative Ruzanna Manukyan and explained the reason for the visit. The administrator Emma Arutiunian arrived shortly.

The LPA and the facility representative conducted a tour of the physical plant at approximately 12:00 p.m. There are (6) bedrooms for residents and (1) bedroom for staff use only. At 12:50 p.m. smoke alarms and carbon monoxide detector were tested and functioning at time of the visit. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Fire extinguisher was fully charged and purchased on 04/11/2024.

KITCHEN: The kitchen appeared clean and the appliances and fixtures functional during the time of visit, sharp objects are stored in locked kitchen drawer. Some cleaning supplies and disinfectants were observed stored inaccessible to residents under the sink. The LPA observed a sufficient amount of perishable and a seven-day supply of non-perishable food at the facility properly stored. At 12:10 p.m. hot water was measured and read 112.5 degrees Fahrenheit.

BEDROOMS: The residents’ bedrooms were properly furnished with at least one chair, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate clean bedding and linens such as sheets, pillowcases, and blankets. While conducting the plant tour, LPA observed that the sketch provided to the department by the facility is outdated. Back up administrator agreed to submit a new sketch to reflect floor plan accurately. Administrator is aware that facility may need to have the fire department to conduct a visit and obtain a new fire clearance if changes are made.

Continues on LIC809_C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BASSETT ASSISTED LIVING	FACILITY NUMBER: 197609920
	VISIT DATE: 07/29/2024

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Continued form LIC 809

BATHROOMS: All bathrooms were clean, properly supplied and had functional fixtures. LPA observed grab bars and non-skid mats in the bathroom. Between 12:00 p.m. and 12:35 p.m. the hot water was measured in each bathroom during physical plant tour. Hot water measured within the required limit of 105-120 degrees Fahrenheit.

COMMON AREAS: The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. The facility maintained a comfortable temperature of 76 degrees Fahrenheit. The LPA observed the required postings in the entry way and common sitting area.

LAUNDRY ROOM: The LPA observed laundry room located right outside the hallway pass bedrooms #5 and #6. Cleaning supplies were stored in cabinets above washer and dryer and inaccessible to residents in care at this time. LPA also observed enough non-perishable supplies,water and emergency food was located inside the closet in a closet inside the laundry room.

GARAGE/OFFICE: LPA observed an office area (converted garage) with a couch, a desk, a file cabinet and a chair. Additionally, LPA observed an extra refrigerator for perishable foods.

OUTDOORS: The front yard exits were clear of hazards and obstructions. The two front side gates have a
self-latching door. At the back of the facility there is an area with outdoor furniture for residents’ use. There are no bodies of water on the premises.

RECORDS: Records review began at 11:00 a.m. LPA reviewed five (5) residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Also, LPA reviewed four (4) personnel records including licensee. These were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

Continues on LIC 809-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BASSETT ASSISTED LIVING	FACILITY NUMBER: 197609920
	VISIT DATE: 07/29/2024

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Continued from LIC 809-C

MEDICATIONS: Medications review began at 2:42 p.m., medications are centrally stored and locked in a cabinet in the living room area; medications are labeled and checked for expiration dates. Medications are properly documented on the Centrally Store Medication and Destruction record as of the time of the visit. LPA observed that administrator keeps a complete first aid kit and manual locked inside the medication cabinet.

No citations were issued. Exit interview conducted. Hard copy of this report issued to Administrator.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

LIC809 (FAS) - (06/04)

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