197610340-4-12-2023-31-AS-MRUZ-CQTRQD-20230412131322

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610340
Report Date: 04/12/2023
Date Signed: 04/12/2023 01:14:11 PM

Document Has Been Signed on 04/12/2023 01:14 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:	COMFORT CARE ASSISTANT LIVING		FACILITY NUMBER:	197610340
ADMINISTRATOR:	BARSEGHIAN, YULIA		FACILITY TYPE:	740
ADDRESS:	19431 ENADIA WAY		TELEPHONE:	(818) 578-5184
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY:	6	CENSUS: 4	DATE:	04/12/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Lelet & Angela Dilanchyan		TIME COMPLETED:	01:00 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	On 4/12/2023 at 10:30 a.m., Licensing Program Analysts (LPA) Melissa Ruiz conducted an unannounced Pre-Licensing visit to this facility and met with applicant Yulia Barsegian. This is a Change of Ownership Application from facility #197609597 to #197610340. A fire clearance dated 1/12/2023 was received for six (6) residents, of which five (5) could be non-ambulatory residents, and one (1) bedridden in Room #2. Facility has submitted a hospice waiver for six (6) residents. The purpose of today’s visit is to inspect the facility to ensure that it maintains compliance under California Code of Regulations, Title 22, Division 6. Today’s site visit consisted of LPA touring the physical plant inside and outside and observed the following: The facility has dual carbon monoxide and smoke alarm system. There is a fire extinguisher, which appears to be fully charged. There is a functioning telephone on the premises. An emergency exit plan/sketch is posted along the hallway wall with other posting requirements. There are three resident bedrooms, which are shared. Resident bedrooms were observed to be appropriately furnished. 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. Resident and staff records are stored in a locked cabinet in the designated office area. Medications are centrally stored in a locked. The first aid kit is readily available. Bathrooms have non-skid mats and appropriate grab bars. Trash cans did not have closed tight fitting lids. (CONT. on LIC809-C)

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

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: COMFORT CARE ASSISTANT LIVING	FACILITY NUMBER: 197610340
	VISIT DATE: 04/12/2023

NARRATIVE

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The kitchen knives are stored in a locked cabinet. The chemicals and cleaning supplies are stored in a locked cabinet in the laundry area. 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. Facility appears to be clean and in good repair. Appliances in the kitchen appeared to be functional.

There is a sitting area in the backyard that is shaded. The backyard is fenced. The garage is detached to the house and it is used for storage. There are no bodies of water on the property.

Component III was conducted with applicant.

During today's visit, facility was cited under "Better Days Assisted Living", due to S1 not being able to communicate or understand English. LPA was unable to communicate with S1, and 3 out of 4 resident interviews revealed that there is a communication boundary between S1 and the residents.

The licensee shall do the following:

Purchase trash cans with closed tight fitting lids
Hire new staff, who speak English
Remove the bedroom furniture location in the living room area.

You will be notified by the CAB Analyst when your license has been approved. This report will be forwarded to the Centralized Application Bureau (CAB) upon completion of the items above. Exit interview was conducted with Licensee. A copy of this report was signed and delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

LIC809 (FAS) - (06/04)

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