197609927-11-18-2021-31-AS-NRED-C8VVHB-20211118152653

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609927
Report Date: 11/18/2021
Date Signed: 11/18/2021 03:27:55 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ASSISTED SENIOR CARE FACILITY		FACILITY NUMBER:	197609927
ADMINISTRATOR:	ANZHELIKA, ALIKHANYAN		FACILITY TYPE:	740
ADDRESS:	7039 CLAIRE AVE		TELEPHONE:	(818) 988-9724
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY:	6	CENSUS:	DATE:	11/18/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:23 PM
MET WITH:	Anzhelika Alikhanyan		TIME COMPLETED:	03:30 PM

NARRATIVE

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On 11/18/2021 at 1:23 PM, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with Staff and Administrator and disclosed the reason for the visit. LPA conducted the visit under the Infection Control Domain of Licensing’s Compliance and Regulatory Enforcement (CARE) Tools.

The census of residents was 6.

At 1:31 PM, LPA inspected the facility inside and out.

The facility has 5 bedrooms. Four bedrooms are private, and one bedroom is shared. Two bathrooms are located in the main hallway and in the shared bedroom.

LPA observed one central entry point designated for the screening of all residents, staff, and visitors, 2 bottles of hand sanitizer available upon entry, and a sign-in log for visitors and staff. LPA asked if Facility maintains a symptom screening and temperature log. LPA advised Administrator to maintain a symptom screening log (+/- temperature and symptom check) for all staff, residents, and visitors.

LPA observed a sign posted at facility entrance with updates to visitation policy to protect residents from infection during pandemic. Signs were posted by the main entry point to promote handwashing, coughing and sneezing etiquette, physical distancing, symptoms of COVID-19, Droplet Precautions, and proper cleaning techniques.
LPA observed facility’s designated visitation area outside. During facility tour, Administrator showed LPA a PPE storage room. LPA observed sufficient supplies of N95 respirators, surgical masks, hand sanitizers, gowns, gloves, and face shields. LPA saw 2 out of 2 bathrooms stocked sufficiently with liquid soap, paper towels, operating sinks, handwashing signs, and trash cans with tight-fitting lids. Beds in the shared room were observed at least 6 feet apart.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ASSISTED SENIOR CARE FACILITY	FACILITY NUMBER: 197609927
	VISIT DATE: 11/18/2021

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At 3:14 PM, LPA observed 6 out of 6 residents’ vaccination records.

While reviewing the facility’s Mitigation Plan, Administrator explained several aspects of the plan, including:

Administrator assured all residents have been notified about facility infection control policies. Administrator also noted the facility has procedures for when to test staff and residents to monitor the spread of the virus and mitigate outbreaks, and the facility tests staff for COVID-19 during hiring process and residents before admission. Administrator stated residents with COVID-19 would be isolated in their own room. If a resident in a shared room tests positive for COVID-19, the facility can provide a private room to the non-positive resident while the positive resident isolates. LPA observed extra trash cans with tight-fitting lids for potential isolation rooms.
Administrator and staff remind all individuals to use cough etiquette and to wash their hands or use hand sanitizer if they cough, sneeze, touch their face, or come in contact with bodily fluids. Residents with symptoms of COVID-19 and awaiting test results are isolated.

Administrator has not provided all staff who are working with COVID-19 positive residents with fit testing for N95 respirators. LPA advised Administrator to obtain Fit testing for staff.

Facility has specific procedures for testing, isolation and quarantine of residents in accordance with Community Care Licensing Division and public health guidance. Facility developed procedures to screen, isolate, test, and accept back residents following discharge from hospital. Administrator is designated to coordinate preparedness planning and integrate local Department of Public Health, California Department of Public Health and Center for Disease Control guidance. Administrator also provides education to staff, residents and visitors on infection prevention including proper donning and doffing of Personal Protective Equipment (PPE). Administrator also monitors staff on a regular basis to ensure they are adhering to infection prevention and control guidelines. Facility has a contingency plan for backup staffing. Facility has developed policies for screening residents after they return from an outing. Internal group activities have been modified to foster physical distancing practices, though Administrator notes residents tend to remain in their rooms.

Facility has a Mitigation Plan to reduce the spread of COVID-19 in the facility.

Facility has not followed the Mitigation Plan these areas:
LPA observed staff not wearing mask. LPA issued Technical Advisory.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021

LIC809 (FAS) - (06/04)

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