197610318-9-18-2024-31-AS-MCAA-D98TQB-20240918145539

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610318
Report Date: 09/18/2024
Date Signed: 09/18/2024 02:55:44 PM

Document Has Been Signed on 09/18/2024 02:55 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:	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:	09/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:19 AM
MET WITH:	Hayk Margaryan, Hovhannes Papazyan		TIME COMPLETED:	03:00 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	In conjunction with complaint control #31-AS-20240909115151, Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with both administrators, Hovhannes Papazyan and Hayk Margaryan and explained the reason for the visit. Today's annual consisted of a physical plant inspection, a review of staff, resident and medication records, and interviews with staff and residents. The facility is a one story building, licensed to serve residents 60 years and above. 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 was purchased on 08/12/24. 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 are five (5) bedrooms designated for residents' use. Bedrooms #1 to #4 are private. Bedrooms #5 is 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 110 degrees Fahrenheit. No cleaning supplies or hazardous items were stored in the bathrooms. Common Areas: These included the living room and dining area. The living room is furnished with two couches, television and table. The fireplace is properly screened. The dining room has a table large enough to seat six (6) residents. 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: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

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

FACILITY NAME: EMERALD SENIOR CARE,INC.	FACILITY NUMBER: 197610318
	VISIT DATE: 09/18/2024

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.

Laundry Room: The laundry area is located by the kitchen. Cleaning supplies and detergents are maintained in the laundry area, which is kept locked at all times. Resident and staff records are kept in a locked cabinet within this area as well.

Staff Office/Work Station: There is a passageway by the kitchen and laundry area, that leads to a converted garage, which is used as staff office. This area is inaccessible to the residents in care.

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 and Medication Records were review for proper storage and 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: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

LIC809 (FAS) - (06/04)

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