197610098-4-23-2023-31-AS-JGTN-CR6R49-20230423124112

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610098
Report Date: 04/23/2023
Date Signed: 04/23/2023 12:41:46 PM

Document Has Been Signed on 04/23/2023 12:41 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:	AFFORDABLE BOARD AND CARE INC.		FACILITY NUMBER:	197610098
ADMINISTRATOR:	KESHISHI, VILBERT		FACILITY TYPE:	740
ADDRESS:	11382 KAMLOOPS ST		TELEPHONE:	(818) 397-5690
CITY:	LAKEVIEW TERRACE	STATE: CA	ZIP CODE:	91342
CAPACITY:	6	CENSUS: 6	DATE:	04/23/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:46 AM
MET WITH:	Vilbert Keshishi - Administrator		TIME COMPLETED:	12:30 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	Licensing Program Analyst (LPA) Gary Tan conducted an unannounced One (1) year Required visit at this facility. LPA met with administrator Vilbert Keshishi and explained the purpose of this visit. A tour of the physical plant was conducted at 9:00 AM and the following was observed: The facility has one main entrance being used, the main door has required Covid-19 prevention signage (hand washing, coughing etiquette and physical distancing) are posted on the door. The PPE screening station is located immediately upon entrance and had a table equipped with sufficient PPE readily accessible, a thermometer, hand sanitizer, gloves, mask and sign in sheet at the time of visit. Visitors are required to wear mask. The facility has an approved mitigation plan on file. The facility is a single storey building and has four (4) bedrooms and two (2) bathrooms. An additional bedroom and one (1) bathroom is designated for staff use. Fire cleared for six (6) non-ambulatory residents, one (1) of which maybe bedridden on Room #1. Hospice waiver for six (6) residents. Living and dining room furniture were checked. The living room is neat and clean along with the dining room. Furniture were observed to be in good repair and excellent condition. The facility maintains a comfortable temperature at 73°F. The dual smoke/carbon monoxide alarm are hardwired and interconnected and observed to be operational. There is a Fire extinguisher is located in the kitchen and observed to be last bought on 04/02/23. (continued on LIC 809-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2023

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: AFFORDABLE BOARD AND CARE INC.	FACILITY NUMBER: 197610098
	VISIT DATE: 04/23/2023

NARRATIVE

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Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked in the kitchen drawer and inaccessible to residents. Laundry area is located in the garage. Laundry detergent, cleaning solutions and other toxins are observed to be locked inside the garage.

The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit. Clients have sufficient amounts of personal hygiene product which is provided by the licensee.

The Bathroom was checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the toilet and shower. The hot water temperature was checked and measured at 114.2°F. Towels and washcloths are not shared. There were enough clean linen available in stock at the cabinet.

Medications: LPA observed that the medication are kept in the cabinet in the kitchen area and was observed to be locked and inaccessible to residents. There was a complete first aid kit located on top of the medication cabinet.

Garage: The garage has access from inside the facility and also being used as frozen and emergency food and other supplies storage. The Backyard had a covered shaded area for clients with outdoor furniture. There is no body of water at the facility.

Client records. All six (6) client records were reviewed. Clients record appeared to be complete and current. Staff records were also reviewed. Four (4) staff records were reviewed, they all have criminal record clearances and associated to this facility. Current training and first aid observed for staff on duty. Administrator's certificate was observed to be current.

Disaster drill was last conducted on 02/23/23. Required posting observed in facility (complaint hot line poster, personal rights, etc).

Exit interview conducted. Copy of this report issued

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2023

LIC809 (FAS) - (06/04)

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