197609995-6-10-2024-29-AS-SURA-D64UX6-20240610155746

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609995
Report Date: 06/10/2024
Date Signed: 06/10/2024 03:58:31 PM

Document Has Been Signed on 06/10/2024 03:58 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
WOODLAND HILLS N.ASC, 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:	06/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Kajo Movsesian		TIME COMPLETED:	02:34 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) Sandra Urena arrived at the facility unannounced to conduct a required annual visit. the LPA met with staff and explained the reason for the visit. The Administrator was called by staff, and Administrator Kajo Movsesian arrived at the facility shortly thereafter. The LPA, and 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. COMMON AREAS: The LPA observed common areas to be relatively clean and properly furnished. The LPA observed the fire extinguishers to be fully charged and last serviced on 02/15/2024. At 12:30 p.m., fire alarms/carbon monoxide detectors were tested and functioned properly. 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. 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. Medications 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 residents’ bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. Continues on LIC 809C...

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HEART OF HOME SENIOR LIVING	FACILITY NUMBER: 197609995
	VISIT DATE: 06/10/2024

NARRATIVE

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RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. Hot water measured at 115.3-degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels.

OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate for client use and is single-latched. No bodies of water were noted.

RECORDS: Records review began at 12:45 p.m., Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 1:30 p.m.; medications are centrally stored and locked in a cabinet in the kitchen area; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

INFECTION CONTROL: 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 a single isolation room if the facility has a confirmed case of COVID-19.

The LPA reviewed the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024

LIC809 (FAS) - (06/04)

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