197610379-4-12-2023-31-AS-APAA-CQTQPM-20230412122057

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610379
Report Date: 04/12/2023
Date Signed: 04/12/2023 12:21:59 PM

Document Has Been Signed on 04/12/2023 12:21 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:	MY HOME FACILITY		FACILITY NUMBER:	197610379
ADMINISTRATOR:	MARGARIAN, ANAHIT		FACILITY TYPE:	740
ADDRESS:	19837 SEPTO STREET		TELEPHONE:	(830) 505-5505
CITY:	CHATSWORTH	STATE: CA	ZIP CODE:	91311
CAPACITY:	6	CENSUS: 2	DATE:	04/12/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Anahit Margarian, Administrator		TIME COMPLETED:	12:50 PM

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At 9:50am, Licensing Program Analysts (LPA) Angela Panushkina conducted a Pre-License visit to this facility and met with Administrator, Anahit Margarian. This is a Change of Ownership Application from facility license number #197610275 to #197610379. A fire Clearance dated 01/18/2023 was received for six (6) residents, of which five (5) could be non-ambulatory residents, and one (1) bedridden in room #1. Facility has a hospice waiver for six (6) residents. The purpose of today’s visit is to inspect the facility to ensure compliance, under California Code of Regulations, Title 22, Division 6.

The facility has a total of five (5) bedrooms, four (4) of which are private and one (1) shared rooms. Resident bedrooms were observed to be appropriately furnished. There are two (2) bathrooms in the facility designated for resident use and were observed to have non-skid mats and appropriate grab bars installed. The facility will have awake staff at night. At 10:15am, the hot water was tested and measured at 108.0°F.

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. The fire extinguisher is located in the kitchen and was purchased on 02/11/2023. Smoke detectors were located throughout the facility, and at 10:50am they were tested and observed to be operational. LPA also tested the carbon monoxide located in a hallway. There is a functioning telephone on the premises. An emergency exit plan/sketch is posted by the entrance. At 11:00am, LPA observed all medications were centrally stored in a locked kitchen cabinet. The first aid kit is readily available. Resident and staff records were also stored in a locked kitchen cabinet. At 11:05am, LPA observed all kitchen knives in the kitchen drawer kept locked and inaccessible to residents in care. The laundry area is located by the attached garage and LPA observed all detergents, cleaning supplies and other toxins are kept locked.

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. Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
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: MY HOME FACILITY	FACILITY NUMBER: 197610379
	VISIT DATE: 04/12/2023

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There is a large covered patio area with swimming pool that is situated behind a secured fence. LPA observed sitting area in the backyard for residents to conduct outdoor activities. The backyard is fenced.

Component III was conducted with the Administrator.

Facility is in compliance with Title 22 Regulations at this time. 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 the Administrator and a copy of this report was signed and issued.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
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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