197610163-9-15-2022-31-AS-TSMH-CJAQLE-20220915121549

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610163
Report Date: 09/15/2022
Date Signed: 09/15/2022 12:15:57 PM

Document Has Been Signed on 09/15/2022 12:15 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:	A & V SENIOR CARE		FACILITY NUMBER:	197610163
ADMINISTRATOR:	GONZALEZ, LORENA		FACILITY TYPE:	740
ADDRESS:	14928 HIAWATHA STREET		TELEPHONE:	(818) 921-0589
CITY:	MISSION HILLS	STATE: CA	ZIP CODE:	91345
CAPACITY:	6	CENSUS: 6	DATE:	09/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Lorena Gonzalez		TIME COMPLETED:	12:25 PM

NARRATIVE

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Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced Annual Required infection Control visit to this facility at 9:40am and observed COVID signs on the front door. LPA Smith observed temperature check station area with sign posted. Temperature checked by Edgar Prepuse. Covid symptoms questions on separate log. LPA informed staff the purpose of this visit. The administrator was called and arrived later.

LPA conducted a tour of the physical plant at 10:15 am to ensure there are no health and safety risks and facility staff are following Title 22 Regulations and the following was noted:

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 cover.

Facility has total of five (5) bedrooms: four (4) for clients: two (2) private bedrooms and two (2) shared bedrooms and one (1) for staff. There are two (2) bathrooms: one (1) located in hallway and one (1) in bedroom #5. There is no body water in the facility.
and nonperishable foods). The kitchen food supply was observed and sufficient for the six (6) clients currently residing there. Two (2) days of perishable fruits, vegetables, milk, and eggs observed with juice. Second refrigerator stocked with excess meats and water stored on floor near staff room. Sharps observed to be locked in drawer in kitchen and inaccessible to clients.
Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition.

Bedrooms were toured and observed to be clean and properly furnished. Linen storage was also checked and observed to have ample supply of clean linen and towels in hallway closet. Locked closet near front door used to store toiletries and incontinent supplies.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

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: A & V SENIOR CARE	FACILITY NUMBER: 197610163
	VISIT DATE: 09/15/2022

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(Cont from 809)

Bathrooms were observed to be clean and sanitary with necessary supplies. Hot water temperature for bathrooms: 114.8- and 117.5-degrees Fahrenheit.

Temperature of facility wall thermostat is observed and set to 76 degrees Fahrenheit.

Laundry area is located in kitchen and appliances observed to be in good repair.
Medications are located in kitchen locked in upper cabinet next to main refrigerator. Medication storage observed to be locked and inaccessible to clients. Two (2) first aid kits stored in medication cabinet observed to be fully stocked.
Smoke alarms and carbon monoxide detectors were present and function properly. There are two (2) fire extinguishers located in kitchen on either side of second refrigerator and observed to be charged.

Garage: Facility does not have a garage.

There is a shed on back side of house used to store sufficient supply of PPEs, additional incontinent supplies, and other equipment. All the toxins, cleaning solutions and disinfectants are store in bottom kitchen cabinet near medications storage. Toxins cabinet observed to be locked and inaccessible to clients.

There is a covered patio with three (3) small patio tables with chairs for clients use. All observed to be clean and furnished with adequate seating. The entry/exits area were clean and free of obstruction. Administrator informed LPA Smith that they are securing new gardener to maintain grounds, shrubs, plants, and fruit trees and will send gardener information on 09/22/2022.

There were no immediate health and safety hazards observed during the day of inspection. There are no deficiencies to report.

Exit interview conducted and a copy of this report printed.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC809 (FAS) - (06/04)

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