197609923-7-13-2022-29-AS-BBAI-CG9UP2-20220712154450

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609923
Report Date: 07/12/2022
Date Signed: 07/13/2022 07:58:22 AM

Document Has Been Signed on 07/13/2022 07:58 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 RESIDENTIAL CARE		FACILITY NUMBER:	197609923
ADMINISTRATOR:	TAVITIAN, HRIPSIME		FACILITY TYPE:	740
ADDRESS:	16017 BASSETT ST		TELEPHONE:	(818) 442-5702
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91406
CAPACITY:	6	CENSUS: 6	DATE:	07/12/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Sona Hakobyan - Caregiver		TIME COMPLETED:	04:00 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) Brian Balisi arrived to this facility today to conduct a One (1) year Required inspection of this facility with emphasis on infection control practices and procedures. LPA met with Caregiver Sona Hakobyan and explained the reason for the visit. LPA spoke with Administrator Hripsime Tavitian over the phone who stated it was okay for Sona to sign for the report. A tour of the physical plant was conducted with Sona approximately between 2:30pm - 4pm LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. The following was noted: There are (6) bedrooms for residents and (1) bedroom for staff use only. Smoke alarms and carbon monoxide detector were tested and functioned properly during time of visit. LPA observed all required postings in the entry area. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Fire extinguishers were fully charged and purchased in April of 2022. Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility properly stored; Sharp objects are stored in lock box that was kept on the counter. LPA observed box to be locked at this time. Some cleaning supplies and disinfectants were observed stored inaccessible to residents under the sink. Bedrooms: The resident bedrooms were properly furnished with at least one chair, night stand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022

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 RESIDENTIAL CARE	FACILITY NUMBER: 197609923
	VISIT DATE: 07/12/2022

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Bathrooms: LPA observed all bathrooms were clean, properly supplied and had functional fixtures. LPA observed grab bars and non-skid mats in the bathroom Residents have sufficient amounts of supplies for personal hygiene properly stored inaccessible to residents. 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: These included the family area by entry way, dining area and living room located between kitchen and hallway to the bed rooms. 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. LPA observed Laundry room to be inaccessible to residents in care at this time. Cleaning supplies were stored in cabinets above washer and dryer. LPA observed cabinets to be locked at this time. There is an attached garage accessible from the outside and the laundry room. LPA observed garage to store an extra fridge and freezer for perishable foods. Extra medical supplies and furniture was also observed in the garage.
Surrounding Grounds (Outdoors): This facility shares a lot with Bassett Assisted Living #197609920. Exit passageways were clear of hazards and obstructions. There is a storage unit located in the far right corner of the property. LPA observed unit to store medical supplies, extra furniture and home maintenance tools. There was a shaded area with proper furniture for outdoor use in the area located outside of living room to the left of the property. There are no bodies of water on the premises. The property is gated was observed to be open at this time. Once the gate is closed, the lock on the entry gate appeared to be single action and inaccessible from the street into the property. At 3pm, LPA observed staff making snacks for the residents.

The LPA spoke with Sona and Hiripsimi via phone regarding the facility’s infection control practices. 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 designate to isolate residents in their private bedrooms, if the facility has a confirmed case of COVID-19. COVID-19 testing is conducted weekly if anyone shows any symptoms. The facility’s policies and procedures as it pertains to infection control are adequate at this time.

Exit interview conducted. Report issued and sent via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022

LIC809 (FAS) - (06/04)

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