197610171-1-29-2024-31-AS-GSAO-CZXS4H-20240129123247

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610171
Report Date: 01/29/2024
Date Signed: 01/29/2024 12:32:58 PM

Document Has Been Signed on 01/29/2024 12:32 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:	HEART TO HEART SENIOR LIVING		FACILITY NUMBER:	197610171
ADMINISTRATOR:	VERONIKA YEBEYAN		FACILITY TYPE:	740
ADDRESS:	9330 ALDEA AVE		TELEPHONE:	(747) 202-0923
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY:	6	CENSUS: 5	DATE:	01/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Veronika Yebeyan		TIME COMPLETED:	12:50 PM

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On 01/29/24 at 09:55 AM, Licensing Program Analyst (LPA) Gina Saucedo, arrived to conduct an unannounced, annual inspection at the facility. Upon arrival, LPA Saucedo met with Caregiver-Armine Hayrapetyan and disclosed the purpose of the visit. The Administrator-Veronika Yebeyan was called and arrived at 10:26 AM.

LPA asked for the census, resident, and staff rosters.

A physical tour was conducted at 11:10 AM and observed the following:

The Kitchen area was toured, and LPA observed there to be sufficient seven (7) day supply of non-perishable foods and perishable food for all residents. The kitchen area was clean at the time of the tour. The fire extinguisher is located against the wall on your left-hand side, next to the sink. It is fully charged with dated 10/2023. There is a telephone line on one of the counters in the kitchen. There is extra, food emergency kits in the kitchen and in the kitchen pantry. The sharps are locked and inaccessible to the residents in one of the upper cabinets. The medication is also locked and inaccessible to the residents in one of the upper cabinets closer to where the table is located.

Outside/Backyard: The outside/backyard has furniture for residents with proper seating. The facility has a signal system. The facility has a pool that is fenced and locked that inaccessible to residents.

LIC 809C-continued

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

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: HEART TO HEART SENIOR LIVING	FACILITY NUMBER: 197610171
	VISIT DATE: 01/29/2024

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Bedrooms: There are six (6) bedrooms. Two (2) bedrooms have private bathrooms. One is single, occupied and one of the bedrooms is currently vacant. The other four (4) bedrooms are single, occupied. All bedrooms and bathrooms were toured and were properly furnished and have appropriate bedding, linens, toiletry and lightning. There are two (2) other bathrooms for resident and staff use. The bathrooms have proper toiletry and grab bars. The bathroom temperatures of the water are within regulations reading at 110–112-degree Fahrenheit.

The dining area/living room area is located next to the kitchen where there is enough seating for the residents and the staff. There is a large television and there is also internet access.

There is a separate area for the laundry. The washer, dryer and toxins are in the right side of the facility towards the back in a large cabinet. There is also extra linen kept in this area.

The carbon monoxide and fire alarms are located throughout the facility and are operable and interconnected.

Administrative: There is no annual fee that is due right now. At the entrance of the facility there is COVID signs, resident roster, YES signs, LGBT, emergency response, house rules, facility sketch, Infection Control, Mitigation Plan and Hospice Approval form against the wall. The disaster plan manual is also located against the wall of the facility. The insurance plan is updated and is dated 01/2024-01/2025.

An exit interview was conducted, no citations were issued, and a copy of this report was given to the administrator.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

LIC809 (FAS) - (06/04)

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