197610018-3-14-2023-29-AS-SURA-CPWVBP-20230314161752

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610018
Report Date: 03/14/2023
Date Signed: 03/14/2023 04:20:04 PM

Document Has Been Signed on 03/14/2023 04:20 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:	AMY'S LOVING CARE		FACILITY NUMBER:	197610018
ADMINISTRATOR:	MELKONYAN, ARMINE		FACILITY TYPE:	735
ADDRESS:	7856 VANSCOY AVE.		TELEPHONE:	(818) 455-9929
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY: 4		CENSUS: 4	DATE:	03/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Armine Melkonyan		TIME COMPLETED:	04:20 PM

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On 03/14/2023, Licensing Program Analysts (LPAs) Ashley Morgan and Sandra Urena, arrived at the facility unannounced to conduct a required annual inspection. LPA’s Morgan and Urena arrived at the facility at 11:10 a.m. The LPA’s met with the Administrator, and inform them for the reason for the visit.

At 11:20 a.m., LPA, 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 and in the living room. Temperature was taken by caregiver, before allowing the LPA’s to enter the premises. Temperature was recorded in sign in sheet.

Common Areas: LPAs 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. Smoke detectors and carbon monoxide detector was tested at 11:36 a.m. and were operational at the time of the visit.

Kitchen: Knives are stored in a locked cabinet drawer. Cleaning supplies are stored in a locked cabinet under the kitchen sink. 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: 03/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

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: AMY'S LOVING CARE	FACILITY NUMBER: 197610018
	VISIT DATE: 03/14/2023

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LPAs observed an adequate supply of Personal Protection Equipment (PPE), and the facility is able to obtain additional supplies as needed.

Bedrooms: The facility has four (4) bedrooms. Three (3) bedrooms are designated for client use. One (1) bedroom is designated for staff use. Bedrooms were furnished appropriately with appropriate furnishings, bed linens, and sufficient lighting.

Bathrooms: There are two (2) bathrooms, one (1) which is designated for residents and one (1) is designated for staff use. 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. Restroom water temperature was recorded at 11:47 a.m. at 105 degrees Fahrenheit.

Outdoor Space: Backyard has a shaded outdoor area equipped with outdoor furniture in good repair for residents’ use. The side gate was self-closing. There were no bodies of water noted.

Files: Records review began at 12:10 p.m. Client 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: job applications, 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 living room; medications are labeled and checked for expiration dates. The LPAs advised the Administrator to ensure that all the information required regarding medications is properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

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

At 3:26 p.m., an interview was conducted with one (1) client and one (1) staff.

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 issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

LIC809 (FAS) - (06/04)

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