197610269-7-11-2023-31-AS-MCAA-CTMSJX-20230711135551

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610269
Report Date: 07/11/2023
Date Signed: 07/11/2023 01:56:22 PM

Document Has Been Signed on 07/11/2023 01:56 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:	HOUSE OF HOPE ASSISTED LIVING, INC		FACILITY NUMBER:	197610269
ADMINISTRATOR:	ALABERKYAN, GAYANE		FACILITY TYPE:	740
ADDRESS:	9617 STANWIN AVENUE		TELEPHONE:	(818) 302-6344
CITY:	ARLETA	STATE: CA	ZIP CODE:	91331
CAPACITY:	6	CENSUS: 3	DATE:	07/11/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:38 AM
MET WITH:	Iuliia Laktionova, Gayane Alaberkyan		TIME COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Michael Cava conducted a Pre-Licensing Inspection. LPA met with staff, Iuliia Laktionova and the Licensee Representative/Administrator, Gayane Alaberkyan. They both were advised of the visit. An Application for a Change in Ownership (CHOW) to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on March 21, 2022. The facility is requesting a fire clearance for six (6) non-ambulatory, of which one (1) may be bedridden. The applicant is also requesting a hospice waiver to retain six (6) residents. The smoke alarms and carbon monoxide detector are dual. Detectors are hard wired and inter-connected. The fire extinguisher is located in the kitchen. It was purchased July 15, 2022. KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven and sink. There is also a mini refrigerator, that was observed to be locked, where insulin is being stored. There is an adequate supply of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). An emergency supply of water was also observed in the kitchen. Sharps and knives were observed locked in a kitchen drawer. BEDROOMS: There are three (3) bedrooms designated for resident use. Bedroom #1 is currently occupied by two (2) residents, and bedroom #2 is occupied by one (1) resident. Bedroom #3 is vacant. All three rooms were furnished with beds, night stand, chairs, dresser, bedding and linen. All three bedrooms have sufficient lighting and closet space. BATHROOMS: The facility has two (2) bathrooms. Bathroom #1 is for resident use. Bathroom #2 is for staff use. Bathroom #1, which is designated for resident use was observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured at 92.7 degrees. No cleaning supplies were observed accessible in the bathroom at this time.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HOUSE OF HOPE ASSISTED LIVING, INC	FACILITY NUMBER: 197610269
	VISIT DATE: 07/11/2023

NARRATIVE

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COMMON AREAS: Facility has one room designated for the living room/activity area. It was equipped with living room furniture, a television, and a coffee table. There is no fireplace. The dining area is located next to the kitchen, There were two small dining room tables observed to accommodate six (6) residents.

LAUNDRY ROOM: The laundry room is located in the garage. Cleaning supplies were stored away and inaccessible to the residents.

MEDICATIONS: Medications are stored locked in one of the kitchen cabinet.

OFFICE/STAFF WORKSTATION: Currently the applicant is utilizing the garage as an office and storage. Desk, office chair and filing cabinet was observed. Staff and resident files are maintained in the filing cabinet there.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. Cameras were observed in common areas and in the front and back yard.There was no auditory buzzer installed at the entry/exit doors. The backyard of the facility has a patio and backyard furniture to accommodate the six (6) residents. The facility backyard has sufficient yard space. There is a swimming pool that is fenced with a gate that will be kept locked at all times. The fence installed to keep residents out of the swimming pool area is approximately 5 feet high throughout the parameters. You will need a key to unlock the padlock to gain entry to the swimming pool as it is kept locked at all times. The swimming pool appears to almost be drained. Water was only observed to be approximately two to three feet high, but it was dirty. Adjacent to the swimming pool was another building, which is used for storage. LPA inspected this building and observed used wheelchairs and beds.

Prior to licensure, the applicant is advised to do the following. Copy of this report provided:

Insure hot water temperature in the bathroom utilized by residents is measured between 105-120 degrees. Applicant will need to measure and log for the next seven days and submit to CCL.
Install an auditory system at each entry/exits in common areas and resident rooms
Drain out the water of the swimming pool.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

LIC809 (FAS) - (06/04)

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