197610102-11-16-2022-31-AS-NRED-CL929E-20221116161149

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610102
Report Date: 11/16/2022
Date Signed: 11/16/2022 04:12:08 PM

Document Has Been Signed on 11/16/2022 04:12 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:	ALLEVIATE CARE		FACILITY NUMBER:	197610102
ADMINISTRATOR:	EDGAR GHAZARYAN		FACILITY TYPE:	740
ADDRESS:	20930 GAULT STREET		TELEPHONE:	(818) 378-2772
CITY:	CANOGA PARK	STATE: CA	ZIP CODE:	91303
CAPACITY:	6	CENSUS: 5	DATE:	11/16/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:55 PM
MET WITH:	Edgar Ghazaryan		TIME COMPLETED:	04:22 PM

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At 2:55 p.m. on 11/16/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. 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 11/23/2021 for an annual visit. It is a single story building with 5 bedrooms, 3 bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for 6 residents, of which 5 may be non-ambulatory. The facility serves residents with dementia. Approved hospice waivers for 5.

Upon entry, LPA observed a sign at the front door for the facility’s visitation policy. Once inside, LPA observed additional postings for COVID precautions, ombudsman contacts, confidential complaint contacts, personal rights, rights of resident councils, emergency disaster plan, facility license, and Administrator certificate. LPA was screened for infectious disease upon entry. The screening station contained a digital thermometer, N95 masks, gloves, sanitizing wipes, and hand sanitizer.

The facility had 5 private bedrooms. All bedrooms contained a chair, nightstand, storage, and bed with adequate bedding. All furnishings were clean and in good condition. One resident was observed watching television in the living room, and LPA spoke with another resident in their room. Both residents reported enjoying the facility and staff.

The facility had 3 bathrooms. All bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At 3:21 p.m. LPA measured the water temperature in the bathroom adjacent to Bedroom #4 to be 119.7 degrees Fahrenheit.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022

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: ALLEVIATE CARE	FACILITY NUMBER: 197610102
	VISIT DATE: 11/16/2022

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LPA observed an adequate supply of perishable and non-perishable foods in the kitchen. Kitchen surfaces were sanitary, and all appliances were functional. Sharps were locked below the counter, and cleaning solutions were locked below the sink. LPA observed an operable washer and dryer in the garage. The garage was locked, and detergents were stored inside. Walls, floors, ceilings, windows, and screens were clean and in good repair. At 3:55 p.m. LPA measured the room temperature to be 73 degrees Fahrenheit.

All emergency exit paths were free from obstructions. Exit gates were unlocked. At 3:50 p.m. LPA observed a fully charged fire extinguisher in the kitchen. It was last inspected on 11/10/2020. At 4:06 p.m. LPA tested the dual-function smoke and carbon monoxide detector to be operational. When tested, 3 out of 3 detectors functioned simultaneously, and the fire door closed. 2 out of 2 auditory alarms were on and functioning.

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

Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022

LIC809 (FAS) - (06/04)

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