197610255-11-1-2023-31-AS-GSAO-CX6TCR-20231101143710

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610255
Report Date: 11/01/2023
Date Signed: 11/01/2023 02:38:13 PM

Document Has Been Signed on 11/01/2023 02:38 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:	AMAZING SENIOR CARE ON LASSEN, INC.		FACILITY NUMBER:	197610255
ADMINISTRATOR:	ALADADYAN, YELENA		FACILITY TYPE:	740
ADDRESS:	17127 LASSEN ST		TELEPHONE:	(818) 207-4220
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY:	6	CENSUS: 6	DATE:	11/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Yelena Aladadyan		TIME COMPLETED:	02:30 PM

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Licensing Program Analysts (LPAs) Gina Saucedo and Gary Tan arrived at the facility to conduct an unannounced Annual Inspection. This operating facility has the capacity of six (6) Residential Facility Care for the Elderly. The facility is a single story house and has three (3) bedrooms and three (3) bathrooms. The home has an attached living area that is not accessible to residents. Administrator Yelena Aladadyan lives in this area of the home.

The physical plant was toured inside and out at 11:20 am.

Common Area: LPAs observed the living room furniture to be clean and in good repair. The facility maintains a comfortable temperature at 72 degrees Fahrenheit. The air conditioner is operational. The fireplace is secured in the living room area covered by a black gate.

Resident rooms: All three (3) bedrooms are shared. The three (3) resident rooms are numbered. LPAs observed rooms to have bedding sheets, pillowcase, blankets, night stands, televisions and sufficient lighting for each of the residents sharing the room. The mattresses were also checked for their condition, trash cans were also provided in each room.

Bathrooms: All three (3) bathrooms were toured and checked to make sure bathrooms were clean and in good repair. The hot water temperature measured within regulations of 112.1 degrees Fahrenheit and 113.5. The showers have non-slip bath mats and grab bars.

Medications were kept in a locked cabinet in the bedroom hallway. All medications were properly labeled and inaccessible to residents. There is a complete first aid kit located in the kitchen and easily accessible.

LIC809-C

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

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: AMAZING SENIOR CARE ON LASSEN, INC.	FACILITY NUMBER: 197610255
	VISIT DATE: 11/01/2023

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Kitchen Area: LPAs inspected the kitchen area. The refrigerator was clean and in good operation. Dishes in good repair. Cleaning supplies/toxins were kept locked in the garage being inaccessible to residents. Fire extinguisher was observed to be full and current. Knives and sharp objects were kept centrally stored and locked in a cabinet located in the kitchen. Stove and refrigerator are clean and in good operation. LPAs observed sufficient supply of non-perishable and perishable foods in the cabinet. In addition, there is another refrigerator in the garage stored with extra food. The PPE is stocked in the kitchen area.

Outside: LPAs toured the outside area. LPAs observed a covered shaded area for residents and appropriate outdoor furniture. The facility has no body of water on the premises. There is one gate that is locked leading to the outside area towards the street. There is also ramps provided for wheelchair residents.

Garage: The garage is attached to the facility but there is no access to the door from inside the home only from the outside. It is used for additional storage of food, chemicals and laundry area.

Staff and Residents records were reviewed. All of the residents file reviewed were observed to be complete and updated. Staff present records were also reviewed and observed to be complete and updated.

Other: No firearms observed or will be maintained on the premises. The mitigation and the Infection control were reviewed and there was Covid 19 signs on the wall, hygiene sanitation signs, Ombudsman signs, the fire drill was conducted recently. The staff and the resident files were in a secure/private location. The carbon monoxide is interconnected with the smoke detector.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there was no deficiencies observed during the visit. Exit interview conducted. Report signed and delivered.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

LIC809 (FAS) - (06/04)

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