197609920-7-31-2023-29-AS-SURA-CU9KHU-20230731075540

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609920
Report Date: 07/28/2023
Date Signed: 07/31/2023 07:56:17 AM

Document Has Been Signed on 07/31/2023 07:56 AM - 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:	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:	07/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Ruzzana Manukyan		TIME COMPLETED:	03:36 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) Sandra Urena arrived at the facility unannounced to conduct a required annual visit at 10:30 a.m. LPA met with facility representative Ruzanna Manukyan and explained the reason for the visit. The administrator Emma Arutiunian arrived shortly after at 11:40 a.m. The LPA and the facility representative conducted a tour of the physical plant at approximately 11:00 a.m. There are (6) bedrooms for residents and (1) bedroom for staff use only. Smoke alarms and carbon monoxide detector were 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 07/13/2023. 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. 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. BATHROOMS: All bathrooms were clean, properly supplied and had functional fixtures. LPA observed grab bars and non-skid mats in the bathroom. 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. Laundry room is located right outside the hallway pass bedrooms #5 and #6. The LPA observed laundry room to be inaccessible to residents in care at this time. Cleaning supplies were stored in cabinets above washer and dryer. Continues on LIC 809C...

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

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: BASSETT ASSISTED LIVING	FACILITY NUMBER: 197609920
	VISIT DATE: 07/28/2023

NARRATIVE

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LPA observed cabinets to be locked at this time. The LPA observed an extra refrigerator and freezer for perishable foods.

OUTDOORS: Exit passageways were clear of hazards and obstructions. There was an area with outdoor furniture for residents’ use. There are no bodies of water on the premises.

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 isolate residents in their private bedrooms. The facility’s policies and procedures as it pertains to infection control are adequate at this time.

RECORDS: Records review began at 12:00 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records 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.

MEDICATIONS: Medications review began at 1:12 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. Exit interview conducted. Report issued and sent via email.

Exit interview conducted. Report issued and sent via email.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC809 (FAS) - (06/04)

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