197610349-1-11-2023-31-AS-MRUZ-CMYQPJ-20230111112050

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610349
Report Date: 01/11/2023
Date Signed: 01/11/2023 11:21:43 AM

Document Has Been Signed on 01/11/2023 11:21 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:	HELIOTROPE ASSISTED LIVING		FACILITY NUMBER:	197610349
ADMINISTRATOR:	PLOKHOVA, IREN		FACILITY TYPE:	740
ADDRESS:	16764 ROMAR ST.		TELEPHONE:	(818) 635-1249
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY:	6	CENSUS: 4	DATE:	01/11/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Peter Atoyan		TIME COMPLETED:	11:25 AM

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 1/11/2022, Licensing Program Analyst (LPA) Melissa Ruiz conducted an announced Pre-Licensing visit to this facility and met with applicant Peter Atoyan. This is a Change of Ownership Application. A fire Clearance dated 12/21/2022 was received for six (6) residents, of which five (5) could be non-ambulatory residents, and one (1) bedridden in Room #4. Facility has a hospice waiver for four (4) 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: Facility has a fire extinguisher, with a date of purchase of 3/16/22. There is a functioning telephone on the premises. Emergency exit plan/sketch is posted on the living room wall with other posting requirements. There are (4) resident bedrooms. 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 living area. Medications are centrally stored in a locked file cabinet. The first aid kit is readily available. There are three (3) bathrooms in the facility. One (1) bathroom is designated for staff use only and the two (2) common bathrooms have non-skid mats and appropriate grab bars. Trash cans were observed to 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: 01/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023

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: HELIOTROPE ASSISTED LIVING	FACILITY NUMBER: 197610349
	VISIT DATE: 01/11/2023

NARRATIVE

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The kitchen knives are stored in a locked box. The kitchen cleaning supplies are stored in a locked cabinet under the kitchen sink. 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 for residents to conduct outdoor activities. Laundry service is done outdoors. The backyard is fenced.

Component III was conducted with applicant.

No deficiencies issued with this report. This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. Exit interview was conducted with Licensee Representative Peter Atoyan. 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: 01/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023

LIC809 (FAS) - (06/04)

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