197610318-11-6-2023-31-AS-MCAA-CXBMQC-20231106084829

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610318
Report Date: 11/02/2023
Date Signed: 11/06/2023 08:49:36 AM

Document Has Been Signed on 11/06/2023 08:49 AM - 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:	EMERALD SENIOR CARE,INC.		FACILITY NUMBER:	197610318
ADMINISTRATOR:	HAYRAPETYAN, ELEN		FACILITY TYPE:	740
ADDRESS:	10401 ENCINO AVE.		TELEPHONE:	(747) 300-2232
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	6	CENSUS: 6	DATE:	11/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:04 AM
MET WITH:	Hovhannes Papazyan, Hayk Margaryan		TIME COMPLETED:	12:00 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 an Annual Required visit and inspection of the facility. LPA met with both administrator, Hovhannes Papazyan and Hayk Margaryan and explained the reason for the visit. At approximately 9:15am, with the assistance of both administrators, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are interconnected and dual with the carbon monoxide detector which functions properly. The fire extinguisher is located in the kitchen. It is brand new, purchased on 08/27/23 Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in drawer in the kitchen, observed locked in a case. No cleaning supplies or hazardous items observed accessible in the kitchen. Bedrooms: There were five (5) bedrooms designated for residents' use. Bedrooms #1 and #2 are private. Bedrooms #3, #4, and #5 are shared. All bedrooms utilized by residents were were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 105 degrees Fahrenheit. No cleaning supplies or hazardous items were stored in the bathrooms. Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

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: EMERALD SENIOR CARE,INC.	FACILITY NUMBER: 197610318
	VISIT DATE: 11/02/2023

NARRATIVE

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Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. The outdoor area was free of hazards. The laundry area is located by the kitchen. Laundry area was observed locked. There is a passageway by the kitchen and laundry area, that leads to the garage, which is used as a break room for staff. Resident and staff files are also maintained in the staff break area as it also serves as staff workstation.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medications are kept locked in a room near the kitchen and laundry area. Medications and Medication Records were review for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted, and a Copy of the Report Issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC809 (FAS) - (06/04)

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