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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610018
Report Date: 04/29/2022
Date Signed: 04/30/2022 10:23:55 AM

Document Has Been Signed on 04/30/2022 10:23 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:AMY'S LOVING CAREFACILITY NUMBER:
197610018
ADMINISTRATOR:MELKONYAN, ARMINEFACILITY TYPE:
735
ADDRESS:7856 VANSCOY AVE.TELEPHONE:
(818) 455-9929
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 4CENSUS: 1DATE:
04/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Armine MelkonyanTIME COMPLETED:
11:50 AM
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On 04/29/2022, Licensing Program Analyst (LPA) Sandra Urena, arrived at the facility unannounced to conduct a required annual inspection. This annual inspection had a specific emphasis on infection control practices and procedures. LPA Urena arrived at the facility at 9:30 a.m. The LPA met with the Administrator, and inform them for the reason for the visit.

At 10:15 a.m., LPA Urena and the administrator conducted a tour of the inside and outside the facility to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility is a one-story dwelling located in the front of the property.

Infection Control: Upon entry, the facility has a sign in book, and sanitizing gel. Infection Control signage was visible at entrance. Temperature was taken by caregiver, before allowing LPA Urena enter the premises. Temperature was recorded in sign in sheet.

Common Areas: At 10:25 a.m., LPA Urena and administrator toured the common areas (living room and dining room). The walls and flooring were checked for cleanliness and were observed to be in good condition. Furniture was observed to be clean, appropriate, and in good condition. Fire extinguishers were observed to be serviced within the last year.

Kitchen: At 10:40 a.m., LPA Urena observed the kitchen/dining area. Knives are stored in a locked cabinet drawer. Kitchen appliances were in operable condition. The facility has enough supply of perishable and non-perishable food. Freezer and refrigerator are stocked with a variety of foods. Prepared foods were safely covered with lids.

Continues on LIC 809C...

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2022
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: AMY'S LOVING CARE
FACILITY NUMBER: 197610018
VISIT DATE: 04/29/2022
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LPA Urena observed an adequate supply of Personal Protection Equipment (PPE), and the facility is able to obtain additional supplies as needed.

Bedrooms: At 10: 55 a.m., LPA Urena observed the residents’ bedrooms. Bedrooms were furnished appropriately with appropriate furnishings, bed linens, and sufficient lighting. The facility has three bedrooms, one has double occupancy.

Bathrooms: At 11: 10 a.m., LPA Urena observed the residents’ bathroom. Bathroom was clean, shower area was in clean condition with grab bars and a non-skid mat available. Paper towels were available for drying hands. Hand washing sign was displayed, and sufficient amounts of soap and paper products available.

Outdoor Space: At 11:20 a.m., LPA Urena observed the Outdoor space. Backyard has a shaded outdoor area equipped with outdoor furniture in good repair for residents’ use. There were no bodies of water noted.



The facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies were cited at this time. Exit interview was conducted, the report was reviewed with the administrator and a copy of the report was provided.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022
LIC809 (FAS) - (06/04)
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