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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610379
Report Date: 05/07/2024
Date Signed: 05/07/2024 02:41:35 PM


Document Has Been Signed on 05/07/2024 02:41 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 FACILITYFACILITY NUMBER:
197610379
ADMINISTRATOR:MARGARIAN, ANAHITFACILITY TYPE:
740
ADDRESS:19837 SEPTO STREETTELEPHONE:
(830) 505-5505
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:6CENSUS: 5DATE:
05/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Karine Harutyunyan, Staff TIME COMPLETED:
03:00 PM
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At 12:25am, Licensing Program Analyst (LPA) Angela Panushkina arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA met with Staff #1, who granted access to the facility. LPAs explained the reason for the visit.

At 12:45am LPA conducted a tour of the physical plant and observed the following:

Facility is licensed for capacity of six (6) of which five (5) may be Non-Ambulatory and one (1) bedridden residents. Facility also has a hospice waiver for six (6) residents. There are four (4) bedrooms designated for residents use, and one (1) bedroom is designated for a live-in caregivers. Bedrooms are appropriately furnished and have appropriate lighting. Bathrooms have soap, paper towels and hand washing signs were observed. Extra towels and linens were readily available. During the LPAs did not observe any immediate health and safety concerns. Facility maintains a temperature of 73°F. LPA observed there to be sufficient stock of one-week perishable foods and two-day non-perishable foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Sharps, cleaning supplies and medications are centrally stored and are kept locked in various kitchen cabinets and drawers. The fire extinguisher was observed to be fully charged and was located in the kitchen area. Laundry is located in a hallway, and LPA observed all chemicals and detergents are kept locked and inaccessible to residents in care. LPA observed a clean covered patio and backyard furniture to accommodate the six (6) residents. Smoke detectors and carbon monoxide monitors were tested at 12:00pm and observed to be functional. Between 12:30am to 2:00pm, LPA reviewed records of five (5) clients and two (2) staff. Resident and staff records appeared to be complete and updated. LPA collected Certificate of Liability Insurance and LIC500.

No citations issued during this visit.
Exit interview conducted and copy of this report signed and delivered.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024
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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