197610018-5-22-2024-29-AS-EPEI-D5HPVV-20240522113946

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610018
Report Date: 05/22/2024
Date Signed: 05/22/2024 11:40:03 AM

Document Has Been Signed on 05/22/2024 11:40 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
WOODLAND HILLS N.ASC, 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: 3	DATE:	05/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Armine Melkonyan, Administrator		TIME COMPLETED:	11:50 AM

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 9:37 a.m., the LPA met with staff and explained the reason for the visit. At 9:54 a.m., the Administrator, Armine Melkonyan arrived at the facility. The facility is vendored by North Los Angeles Regional Center as a level three (3) home. Starting at 9:56 a.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 and dining area. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 10:00 a.m., hot water temperature measured at 105.0-degree Fahrenheit. Knives are stored in a locked kitchen drawer. Cleaning supplies are stored in a locked cabinet under the kitchen sink. BEDROOMS: The facility is a single-story residential home with four (4) bedrooms, three (3) for client use and one (1) for staff use. The LPA observed client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. RESTROOMS: The facility has two (2) bathrooms, one (1) for client use and one (1) for staff use. Client restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. At 10:06 a.m., hot water temperature measured at 105.1-degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels. Continued on LIC 809-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

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: AMY'S LOVING CARE	FACILITY NUMBER: 197610018
	VISIT DATE: 05/22/2024

NARRATIVE

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OUTDOOR SPACE: At 10:06 a.m., the LPA observed the back patio which has a covered outdoor area for client use. There are no bodies of water on the premises. The side gate was self-closing.

COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished. The LPA observed the fire extinguishers to be fully charged and purchased on 01/03/2024. At 10:08 a.m., fire alarms/carbon monoxide detectors were tested and functioned properly. Facility telephone was observed during the time of the visit. Night lights were present in the hallways. The laundry units are located inside the laundry area near the kitchen. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in a locked cabinet inside the laundry area.

RECORD REVIEW: Between 10:10 a.m. and 10:47 a.m., the LPA conducted a file review for all clients and staff regularly scheduled and observed the following: Staff have current first aid. Client records were reviewed for, but not limited to current Individual Programming Plan (IPP), medical records, P & I funds, admissions agreement, and consent forms. All files were in order. The LPA also reviewed the following: surety bond, valid liability insurance, Infection Control Plan and Emergency and Disaster Plan. The most recent fire and earthquake drill was conducted on 03/01/2024. At 10:48 a.m., P&I money was reviewed for two (2) clients.

At 10:50 a.m., the LPA conducted a review of medication and medication documentation with the Administrator for three (3) clients and observed that medications were properly documented and assisted as prescribed.

At 11:17 a.m., the LPA conducted an interview with one (1) staff. During the time of the visit, three (3) out of three (3) clients were at day program.

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

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

LIC809 (FAS) - (06/04)

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