197610054-8-21-2020-31-AS-NGID-BSPRU9-20200821131933

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610054
Report Date: 08/21/2020
Date Signed: 08/21/2020 01:19:40 PM

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	LEO'S ASSISTED LIVING II		FACILITY NUMBER:	197610054
ADMINISTRATOR:	GHARIBYAN, ANNA		FACILITY TYPE:	740
ADDRESS:	7567 BOVEY AVENUE		TELEPHONE:	(310) 292-2992
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY:	6	CENSUS: 0	DATE:	08/21/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Armine Arakelian /Anna Gharibyan(Applicant/Administrator)		TIME COMPLETED:	10:40 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) Nichelle Gillyard conducted a pre-licensing visit with Armine Arakelian /Anna Gharibyan(Applicant/Administrator). Due to the situation surrounding the Corona Virus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted by Facetime video conference. Entrance interview conducted. The physical plant was toured inside and out. LPA observed the appropriate Community Care Licensing Complaint Poster( LPA requested size 20X26) . The Bill of Rights and the Right to Residential Council were not posted. LPA emailed the discrimination statement to be posted. The facility has 3 bedrooms and 2 bathrooms designated for a capacity of 6 residents. Rooms available are shared. There are no bedrooms designated for staff. There will be a wake night staff. Fire clearance is approved for 5 non-ambulatory and 1 bedridden in room #1. The licensee will have a dementia plan of operation. The licensee may requested to increase hospice waiver from 2 to 6 during the application process. Physical Plant: The facility maintains a comfortable temperature at 73 degrees F which meet regulations. No fire arms observed or will be maintained on the premises. The smoke alarm and carbon monoxide detector was operational. Fireplace has appropriate screen and is locked. Fire extinguishers appear to be full. Auditory alarms are operational through out the facility. Furniture in the common area appears to be in good repair. No obstructions observed throughout the facility. LPA toured the kitchen area. LPA inspected kitchen equipment. The refrigerator was clean and in good operation. Dishes in good repair. Knives and cleaning supplies will be kept locked inaccessible. LPA discussed maintaining 2 day and one week of non-perishable foods. Medications will be kept centrally stored and locked in a cabinet in the office. The applicant was reminded that the key to the lock cannot be accessible. LPA toured the outside area. LPA observed a covered shaded area for residents. LPA observed appropriate outdoor furniture. No bodies of water on the premises.

SUPERVISOR'S NAME: Maryjo Schnitzer	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Nichelle Gillyard	TELEPHONE: (818) 326-5838
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2020

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LEO'S ASSISTED LIVING II	FACILITY NUMBER: 197610054
	VISIT DATE: 08/21/2020

NARRATIVE

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Resident rooms: Rooms available are shared. LPA observed rooms to have appropriate bedding sheets, pillowcase, mattress pad, and blankets) which are in good condition. There is at least one chair, night stand and sufficient lighting for each client. The mattresses and bedsprings were also checked for condition. LPA suggested bedbug covers for mattresses and box springs.
LPA observed appropriate window covering and screens in window. LPA observed sufficient supplies of personal hygiene products ( soap, shampoo, toothpaste, toothbrushes etc.) which is provided by the Licensee.

Bathrooms: LPA toured resident bathrooms and checked to make sure bathrooms were clean and in good repair. The hot water temperature measured at 107.6 degrees F. LPA observed appropriate non-skid mat in each bathtub. Trash cans have lids to protect consumers from cross contamination. Towels and washcloths will not be shared. The tub in the resident bathroom will not be used. There is a walk in shower.

Kitchen Area: LPA inspected kitchen equipment. The refrigerator was clean and in good operation. Dishes in good repair. Knives and cleaning supplies will be kept locked inaccessible.
Medications will be kept centrally stored and locked in a closet in the kitchen area. The applicant was reminded that the key to the lock cannot be accessible. Stove and refrigerator is clean and in good operation.

The licensee will need to complete the following before the license is approved.

1 New facility sketch labeling the shut off valves and emergency assembly points.
Component III: The Administrator/Applicant has completed component III during the visit.

The facility is ready for operation upon completion component III and of requested items in this report, and final approval of the application. Submit items for correction within 10 days.

The licensee shall notify the licensing agency upon receipt of their first consumer.
Exit interview conducted.

SUPERVISOR'S NAME: Maryjo Schnitzer	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Nichelle Gillyard	TELEPHONE: (818) 326-5838
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2020

LIC809 (FAS) - (06/04)

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