197610096-3-28-2022-31-AS-NRED-CCXRR4-20220328131432

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610096
Report Date: 03/28/2022
Date Signed: 03/28/2022 01:15:38 PM

Document Has Been Signed on 03/28/2022 01:15 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	HEALTHY LIFE SERVICE FACILITY		FACILITY NUMBER:	197610096
ADMINISTRATOR:	TADEVOSYAN, LUSINE		FACILITY TYPE:	740
ADDRESS:	15921 LIGGETT STREET		TELEPHONE:	(747) 254-6056
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY:	6	CENSUS: 5	DATE:	03/28/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:05 AM
MET WITH:	Armine Dishoyan		TIME COMPLETED:	01:20 PM

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

At 11:05 a.m. on 03/28/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and later Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out.

The facility was last visited on 03/08/2021 for a prelicensing inspection. The facility has an approved fire clearance for 6 non-ambulatory residents of which 1 may be bedridden in room #3 or room #4. Hospice waivers for 5 residents. The facility is a single-story building with 4 bedrooms, 2 bathrooms, living room, dining room, kitchen, laundry area, staff office, back yard, and garage. The facility serves residents with Dementia.

Safety: The facility has ramps at the front door and outside of Bedroom #3 and Bedroom #4. All ramps were stable with sturdy handrails. Emergency exit paths, located on the west and east sides of the facility, were free from hazards. Emergency exit doors used inward facing, self-closing latches which were unlocked. Emergency disaster plan and emergency evacuation routes posted and clearly labeled. Auditory alarms on 4 out of 4 doors were on and functioning. A fully charged fire extinguisher hung in the kitchen. LPA observed its receipt from 03/04/2022. At approximately 11:40 a.m. LPA tested smoke and carbon monoxide detector in the living room. The detector was hardwired to others in the building, and all functioned appropriately. The facility uses a call system which signals to the kitchen.

Entry: LPA entered the one main entrance. Upon entry, LPA observed a sign labeled “No Smoking - Oxygen in use”. LPA also observed a sign regarding the updated visitation policy.

Screening: LPA was screened for symptoms of infectious disease upon entry. LPA observed a sign instructing visitors to wash hands upon entry. The screening station contained a digital thermometer, surgical masks, and a visitor log.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: HEALTHY LIFE SERVICE FACILITY	FACILITY NUMBER: 197610096
	VISIT DATE: 03/28/2022

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
26
27
28
29
30
31
32

Bedrooms: The facility has 4 bedrooms for resident use. Bedroom #2 and Bedroom #3 are shared. Bedroom #1 and Bedroom #4 are private. All bedrooms contained a chair, night stand, storage, and beds with adequate bedding. All bedrooms were clean and in good repair.

Bedroom #1 is a private bedroom. Resident was observed resting. Bed had a half bed rail.

Bedroom #2 is a shared bedroom. 2 residents were observed resting. Both beds had full bed rails.

Bedroom #3 is a shared bedroom. 2 residents were in bed. Both beds had full bed rails.

Bedroom #4 is a private bedroom. The bedroom was vacant.

Bathrooms: The facility has 2 bathrooms. One bathroom was private to Bedroom #3. The other bathroom is located near the main entrance. Both bathrooms contained liquid soap, paper towels, handwashing instruction signs, grab bars by the toilet and shower, non-skid mats, and trash cans with tight-fitting lids.

Linen closet: LPA observed a linen closet near Bedroom #1. The closet contained an adequate supply of clean towels and bedsheets. Below the linen closet, LPA observed a locked cabinet which contained hygiene supplies and razors.

Laundry: LPA observed a washer and dryer in good condition. Detergents were locked in a cabinet. Staff had the keys with them.

Kitchen: The facility contained adequate supplies of perishable and non-perishable food. Food was labeled with expiration dates. Stove burners were functioning properly. LPA observed a temperature log for refrigerator and freezer temperatures from the past week.

Common Areas: Facility walls, floors, ceilings, windows, blinds, and window screens were all clean and in good repair. LPA observed a locked office near the dining area. The office was free from hazards.

Outdoors: LPA observed patio furniture in good condition under a shaded canopy. Back yard and front yard lawns were maintained.

During today's visit, the facility is in compliance with Title 22 regulations, no citations issued.

Exit interview conducted. Copy of report issued.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2