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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610177
Report Date: 08/02/2022
Date Signed: 08/02/2022 06:44:59 PM


Document Has Been Signed on 08/02/2022 06:44 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:ANNA'S HOME & PARADISEFACILITY NUMBER:
197610177
ADMINISTRATOR:ARMENYAN, ANNAFACILITY TYPE:
740
ADDRESS:23463 HAYNES STTELEPHONE:
(323) 660-0001
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:6CENSUS: 5DATE:
08/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Anna ArmenyanTIME COMPLETED:
06:15 PM
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced required annual visit. LPA met with administrator and explained the reason for the visit. Covid Protocols were followed. LPA's temperature and covid check were done upon entering the facility.
LPA toured the physical plant of the facility. There are 5 resident bedrooms, 4 private and 1 shared room. No room is designated for staff use. Resident bedrooms were observed to be appropriately furnished with a bed, nightstand, a chair and extra linens. The common areas (living room, kitchen and dining areas) were appropriately furnished and lighting was adequate. The living room has a television and comfortable furniture. The fire extinguisher is located in the dining area and was observed to be fully charged. Dual Smoke and Carbon Monoxide detectors were observed all over the facility, tested and observed to be operational. Water was tested in the common bathrooms and measured at 117°F. There is a functioning telephone/landline on the premises. An emergency exit plan/sketch is posted near the entrance wall with other posting requirements. There are 2 bathrooms in the facility. The common bathrooms have non-skid mats, trash cans with lids and functional grab bars. The sharps, are stored and locked in the pantry. Kitchen cleaning supplies, laundry detergents, cleaning supplies and other toxins are stored and locked in the garage. The laundry is located in the hallway and appears to be functional. The facility has a variety of adequate perishable and non-perishable food supply. The necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on all doors and locked areas for centrally stored medications. Appliances in the kitchen appeared to be functional. Facility appears to be clean and in good repair. There is a large sitting area and a large gardening area in the backyard for residents to conduct outdoor activities. The backyard is fenced. The garage is attached to the house but is kept locked from the inside. There is no body of water in the facility.
No deficiencies cited. Exit Interview conducted.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2022
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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