197610096-5-21-2023-31-AS-TSMH-CS2U7V-20230521152035

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610096
Report Date: 05/21/2023
Date Signed: 05/21/2023 03:20:39 PM

Document Has Been Signed on 05/21/2023 03:20 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., 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:	(818) 810-5955
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY:	6	CENSUS: 5	DATE:	05/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Arusyak Ohanyan		TIME COMPLETED:	03:25 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 8:50 am Licensing Program Analyst (LPA), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility. LPA was greeted by facility staff and disclosed the purpose of the visit. The administrator was contacted, and the Licensee and Administrator arrived later. LPA conducted a tour of the physical plant at approximately 9:30 am to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Common areas were observed for the ability to safely serve the needs residents. These included the living room and kitchen/dining combination. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to be furnished appropriately with adequate seating for residents. LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the five (5) residents currently residing there. Two (2) days of perishable food 7 days non-perishable food observed. The freezer is stocked with meats and frozen vegetables. Sharps stored and locked in kitchen drawer and medications are stored in locked hall closet next to main entry door. Sharps and medications observed to be inaccessible to residents. There is one (1) fire extinguisher: attached to wall in kitchen. Laundry room is located through the kitchen in separate alcove area. The appliances observed to be functional. Toxins stored in cabinets across from washer and dryer and observed to be locked and inaccessible to residents. The facility has a total of five (5) bedrooms and three (3) bathrooms. The resident bedrooms were properly

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2023

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HEALTHY LIFE SERVICE FACILITY	FACILITY NUMBER: 197610096
	VISIT DATE: 05/21/2023

NARRATIVE

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(Cont from 809)

furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed a supply of linens in hall closet with a supply of hygiene products on bottom section of closet.

Each bathroom has posted “wash your hands” signs and the following items available: hand soap, paper
towels, and trash cans. The hot water temperature was measured for the three (3) bathrooms to ensure it is
within the required range for residents’ comfort and safety. The water temperature range was between 125 -128.8 degrees Fahrenheit with hot water caution signs present.

Backyard has the following: Large Gazebo with table with chairs and three (3) separate patio areas. Patio furniture observed to be in good repair

No garage at facility

Smoke detectors/carbon monoxide detector were tested and operable at time of visit.

Facility grounds were free of hazards. There were no immediate health and safety hazard observed during the day of inspection.

At approximately 11:30 pm,LPA reviewed files for the five (5) residing residents. Resident files included physicians’ assessment, needs and services appraisals. Staff files reviewed for four (4) staff. Staff files had medication training's, dementia training's, certificate including current First aid/CPR certificates.

No Deficiencies cited. Exit interview conducted and reported given

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2023

LIC809 (FAS) - (06/04)

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