197609995-12-20-2022-29-AS-EPEI-CMAT3A-20221220132201

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609995
Report Date: 12/20/2022
Date Signed: 12/20/2022 01:22:43 PM

Document Has Been Signed on 12/20/2022 01:22 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: 5	DATE:	12/20/2022
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	10:57 AM
MET WITH:	Kajo Movsesian, Administrator		TIME COMPLETED:	01:30 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) Emily Peraldi arrived at the facility unannounced to conduct a Random Annual two-year Compliance Plan visit. At 10:57 a.m., the LPA met with the Administrator and explained the reason for the visit. This annual had a specific emphasis on physical plant/environmental safety and food services practices and procedures. At 11:45 a.m., the LPA, along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. KITCHEN: The LPA observed the kitchen/dining area. Knives are stored in a locked kitchen cabinet. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 11:50 a.m., hot water measured at 105.2-degree Fahrenheit. Medications and first aid kits are located in a locked kitchen cabinet. At 11:55 a.m., the LPA observed staff preparing lunch. 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 11:41 a.m., hot water measured between 106.6 and 109.6-degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels. At 11:46 a.m., the LPA observed Lysol disinfectant underneath the sink. Once observed, the Administrator locked away the Lysol disinfectant. 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: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

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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Document Has Been Signed on 12/20/2022 01:22 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as there was a disinfectant accessible, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/20/2022
	Plan of Correction
1 2 3 4	The Administrator has agreed to do the following: 1. The items were removed upon observation. Plan of Correction met.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

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: 12/20/2022

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COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished. The LPA observed the fire extinguisher to be fully charged and serviced on 11/03/2022. Signs are posted throughout facility to promote handwashing, and cough/sneeze etiquette. At 11:56 a.m., the fire alarms/carbon monoxide detectors were tested and functioned properly. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station.

OUTDOOR SPACE: At 12:02 p.m., the LPA observed the back patio which has a covered outdoor area for resident use. There is a self-latching gate on the side of the house designated for an emergency exit. There were no bodies of water noted

At 12:15 p.m., the LPA confirmed that three (3) out of four (4) residents have dementia. The Administrator understands that disinfectants need to be stored inaccessible to residents with dementia.

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 809-D). Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. Report issued, and a copy of the report and appeal rights was provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC809 (FAS) - (06/04)

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