197610144-12-27-2023-31-AS-CALH-CYWUTA-20231227145133

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610144
Report Date: 12/27/2023
Date Signed: 12/27/2023 02:51:59 PM

Document Has Been Signed on 12/27/2023 02:51 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	VICTORIA'S DIGNITY CARE		FACILITY NUMBER:	197610144
ADMINISTRATOR:	BERGHOUDIAN, JACK J		FACILITY TYPE:	740
ADDRESS:	13874 KELOWNA ST.		TELEPHONE:	(818) 894-5761
CITY:	ARLETA	STATE: CA	ZIP CODE:	91331
CAPACITY:	6	CENSUS: 6	DATE:	12/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:29 AM
MET WITH:	Jack Berghoudian		TIME COMPLETED:	02:50 PM

NARRATIVE

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On 12/26/2023 at 09:29 AM, Licensing Program Analyst (LPA) Christopher Alemoh conducted an unannounced Required – Annual Continuation Inspection and met with Administrator Jack Berghoudian. Five (5) residents and three (3) staff were present during this inspection.

Facility is licensed to serve four (4) non-ambulatory residents, one (1) may be bedridden in any room. The facility also has an approved hospice waiver for six (6) residents. The facility currently has 4 non-ambulatory residents. Hospice waiver for 4 residents. Age range of residents 60 and over. The Annual Licensing Fees are current.

Facility has four (4) four bedrooms: (3) three shared bedrooms for clients and (1) bedroom designated as employee room. There are two (2) bathrooms: (1) one for clients located in hallway near client’s bedrooms #1 and #2. There is no body water in the facility.

LPA conducted a tour of the physical plant at 9:40 am to ensure there are no health and safety hazards and facility staff are following Title 22 Regulations and the following was noted.

S1 and S3 accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured, there are (3) three covered patio sections: (2) two for clients use and (1) for staff use. All observed to be clean and furnished with adequate seating, and no bodies of water were observed. Walkways around the home were clear of hazards.

Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Christopher Alemoh	TELEPHONE: 818-669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VICTORIA'S DIGNITY CARE	FACILITY NUMBER: 197610144
	VISIT DATE: 12/27/2023

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Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, hot water temperature properly measured between 109F-110F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Hand washing, coughing etiquette, physical distancing, and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with covers.

LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxics were kept in locked storage cabinet. First Aid kit and manual was located near the administrator desk.Three (3) fire extinguishers in the facility: one (1) in foyer/waiting room, one (1) in the living room and one (1) in the kitchen. Extinguishers were observed to be charged with receipt dated June 12th, 2023. Dual Smoke alarms and carbon monoxide are hardwired and interconnected, were tested and observed to be operable.

Medications are located in the kitchen locked in separate wood file cabinet. A locked mini fridge situated on top of medication file cabinet holds prescription eye drops and diabetes medication. Medication was observed to be inaccessible to clients. The first aid kit located in foyer near administrator workstation observed to be fully stocked.
At 10:40AM LPA conducted a facility file review.

5 staff records were reviewed, 5 out of 5 staff records had current first aid certificates and had required criminal record clearances or criminal record exemptions.

5 resident records were reviewed and, 5 out of 5 client records had Admission Agreements, Medical Assessments, Pre-appraisals (or Reappraisals) and/or Needs & Services Plans.

No deficiencies cited.

An exit interview was conducted. A copy of this report and appeal rights were left with Administrator Jack Berghoudian.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Christopher Alemoh	TELEPHONE: 818-669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

LIC809 (FAS) - (06/04)

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