197609995-6-27-2023-29-AS-EPEI-CT7U87-20230627152105

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609995
Report Date: 06/27/2023
Date Signed: 06/27/2023 03:22:21 PM

Document Has Been Signed on 06/27/2023 03:22 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:	06/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Kajo Movsesian, Administrator		TIME COMPLETED:	03:30 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 required annual visit. At 1:25 p.m., the LPA met with staff and explained the reason for the visit. At 1:40 p.m., the Administrator arrived at the facility. At 1:56 p.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 1:58 p.m., hot water measured at 105.8-degree Fahrenheit. Medications and first aid kits are located in a locked kitchen cabinet. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away inside a kitchen cabinet. BEDROOMS: The facility is a single-story residential home with four (4) bedrooms and two (2) bathrooms for resident's use. 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 2:02 p.m., hot water 110.3-degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels. 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: 06/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023

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: HEART OF HOME SENIOR LIVING	FACILITY NUMBER: 197609995
	VISIT DATE: 06/27/2023

NARRATIVE

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OUTDOOR SPACE: At 2:04 p.m., the LPA observed the back patio which has a covered outdoor area for resident use. There is a gate on the side of the house designated for an emergency exit. There are no bodies of water on the premises. At 2:04 p.m., the LPA observed car tires in the backyard. Licensee stated that the car tires will be removed from the facility. The facility has an accessory dwelling unit (ADU) on the side of the facility and is not part of the license. The ADU remains inaccessible to residents.

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 last serviced on 11/03/2022. At 2:06 p.m., fire alarms/carbon monoxide detectors were tested and functioned properly. Night lights were present in the hallways and passages. All exits have functioning auditory devices and were operational at the time of the visit. There is a washer and dryer located in one of the hallways.

Between 3:08 p.m. and 3:12 p.m., the LPA conducted interviews with two (2) staff.

Due to time constraints the LPA will return to complete the annual at a later date.

Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023

LIC809 (FAS) - (06/04)

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