197610002-7-15-2022-29-AS-SWAR-CGCNWY-20220715105018

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610002
Report Date: 07/15/2022
Date Signed: 07/15/2022 10:51:05 AM

Document Has Been Signed on 07/15/2022 10:51 AM - 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:	JASMINE		FACILITY NUMBER:	197610002
ADMINISTRATOR:	SARGSYAN, ARMAN		FACILITY TYPE:	740
ADDRESS:	7331 KATHERINE AVE		TELEPHONE:	(818) 785-4230
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY:	6	CENSUS: 5	DATE:	07/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Arman Sargsyan, Administrator		TIME COMPLETED:	11:00 AM

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Licensing Program Analyst (LPA) Salia Walker arrived at the facility unannounced to conduct a required Annual visit. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Arman Sargsyan at 10:10 a.m., and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside, with staff at 9:46 a.m., to ensure there are no health and safety hazards.
BEDROOMS: The LPA observed the resident bedrooms which were furnished with clean linens, appropriate furnishings, and sufficient lighting.
RESTROOMS: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap, paper products, and hand-washing signs in each restroom. From 9:55 a.m. until 10:01 a.m., hot water temperatures measured between 112.7 and 118.8 degrees Fahrenheit in the common and private restroom(s).
KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be properly stored and locked at time of visit. Hot water measured 117.6 degrees Fahrenheit at 9:50 a.m.
COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed required postings in the hallway. One (1) fire extinguisher was observed to be fully charged and purchased on 07/19/21.
BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. The garage is attached to the facility, and is currently utilized for additional storage.

Continue on LIC809C..

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-326-5838
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022

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: JASMINE	FACILITY NUMBER: 197610002
	VISIT DATE: 07/15/2022

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INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed 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. The Infection Control plan has not yet been submitted, and the Administrator will submit to CCL. This facility has records of staff and resident vaccinations. The facility can designate a single-person room to isolate persons if there is a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time and the LPA reviewed facility’s policies, and procedures as it pertains to infection control.

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

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-326-5838
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022

LIC809 (FAS) - (06/04)

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