197609995-5-5-2022-29-AS-EPEI-CE5R42-20220505124050

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609995
Report Date: 05/05/2022
Date Signed: 05/05/2022 12:41:55 PM

Document Has Been Signed on 05/05/2022 12:41 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	HEART OF HOME SENIOR LIVING		FACILITY NUMBER:	197609995
ADMINISTRATOR:	MOVSESIAN, KAJO		FACILITY TYPE:	740
ADDRESS:	6425 NAGLE AVE		TELEPHONE:	(747) 247-2365
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91401
CAPACITY:	6	CENSUS: 4	DATE:	05/05/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:27 AM
MET WITH:	Tatevik Grigoryan, Staff		TIME COMPLETED:	12:50 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	At 11:27 a.m., Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted and screened by staff. The Administrator was not available during the time of the visit. At 11:29 a.m., the LPA spoke with the Administrator on the phone, and the Administrator authorized staff, Tatevik Grigoryan to sign the report. This annual had a specific emphasis on infection control practices and procedures. At 11:35 a.m., the LPA, along with staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: At 11:35 a.m., the LPA observed the kitchen/dining area. Knives are stored in a locked cabinet. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 11:43 a.m., hot water measured at 105.5-degree Fahrenheit. Medications and first aid kits are located in a locked kitchen cabinet and drawer. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away. At 12:00 p.m., the LPA observed a resident reading a book at the dining table. COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished. The LPA observed puzzles and books in the common area. The LPA observed the fire extinguisher to be fully charged and last serviced on 05/27/2021. Flashlights were observed throughout the facility. Upon entry, signs are posted to promote handwashing, cough/sneeze etiquette, and physical distancing. At 11:46 a.m., fire alarms and carbon monoxide detectors were tested and functioned properly. The laundry units are located inside a hallway closet. Continued on LIC 809-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022

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: HEART OF HOME SENIOR LIVING	FACILITY NUMBER: 197609995
	VISIT DATE: 05/05/2022

NARRATIVE

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BEDROOMS: The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level.

RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. At 11:44 a.m., hot water measured at 112.8-degree Fahrenheit. Night lights were present in the hallways and passages.

OUTDOOR SPACE: At 11:39 a.m., the LPA observed the backyard, which has a covered outdoor area for resident use. There is a gate on the side of the house that is single latched designated for an emergency exit. Passageways were free and clear from obstruction.

INFECTION CONTROL: During today’s visit, the LPA spoke with the staff regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station. LPA observed a 30-day 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 a single isolation room if the facility has a confirmed case of COVID-19. The facility has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies were observed at this time. Exit interview conducted with staff. Report issued and a copy of the report was emailed to the Administrator.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022

LIC809 (FAS) - (06/04)

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