197610392-5-16-2023-31-AS-ERIS-CRVQPJ-20230516122050

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610392
Report Date: 05/16/2023
Date Signed: 05/16/2023 12:20:54 PM

Document Has Been Signed on 05/16/2023 12:20 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	JUDD ASSISTED LIVING		FACILITY NUMBER:	197610392
ADMINISTRATOR:	AVANESYAN, LIANA		FACILITY TYPE:	740
ADDRESS:	12615 JUDD ST		TELEPHONE:	(747) 240-9360
CITY:	PACOIMA	STATE: CA	ZIP CODE:	91331
CAPACITY:	6	CENSUS: 0	DATE:	05/16/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Liana Avanesyan		TIME COMPLETED:	12:30 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 5/16/2023, Licensing Program Analyst (LPA) Evelin Rios conducted an announced Pre-Licensing visit to the facility mentioned above. LPA met with applicant Liana Avanesyan. The purpose of today’s visit was explained. This is an initial application for an RCFE. A fire clearance dated 12/16/2022 was received for five (5) non-ambulatory residents and one (1) bedridden resident. At 9:45 a.m. LPA and applicant toured the physical plant inside and out. LPA observed the following: Living Room: The living room is furnished with comfortable seating and a television. Kitchen: The facility has one fire extinguisher located on a wall by the kitchen that was observed fully charged with purchased date of 4/27/2023. There are two functioning telephones on the premises, one by the kitchen and the other by the dining table. Knives were locked in a kitchen drawer. Centrally stored medications will be locked in a kitchen cabinet. First aide kit was locked in the same cabinet. The pantry contained a seven-day supply of non-perishable foods and the refrigerator contained a 2-day supply of non-perishable foods. LPA observed the facility menu posted on the kitchen refrigerator. LPA observed enough plates, cups and silverware for the capacity of the facility. A stacked washer and dryer are located in the kitchen and observed to be operational. Laundry detergent and cleaning products are kept locked in the garage and will be inaccessible to residents. The facility PPE is stored in a kitchen drawer. Dining Area: LPA observed a dining table with chairs able to seat the capacity of the facility. Resident and staff records will be kept in a locked cabinet in the dining area. A screened fire place was observed and is not in use. Hallway Closets: Hallway closets contained extra clean linens and bathroom supplies. LPA observed board games and activities for residents. The emergency exit plan/sketch is posted on the walls throughout the facility. (LIC809-C continued on to next page)

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: JUDD ASSISTED LIVING	FACILITY NUMBER: 197610392
	VISIT DATE: 05/16/2023

NARRATIVE

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(LIC809-C Continued)
Bedrooms: There are three (3) resident bedrooms meant to be shared by two residents. Each bedroom has two new twin beds with linens, two night stands, two lamps, two chairs and either a closet or cabinet with drawers for resident storage. Room 3 will accommodate either two residents or be used as a single bedroom. Bedroom number 2 has fire clearance for one bedridden resident.

Bathrooms: There are two (2) bathrooms in the facility. One bathroom is located in Room 3 for private use of the the residents. There is another bathroom located in the hallway. The bathrooms contained, hand soap, paper towels, toilet paper, and covered trash bins. The residents’ personal hygiene items are locked under bathroom sink cabinets. At 10:30 a.m. LPA tested the water temperature in the resident's hallway bathroom, water temperature read at 108 degrees F.

Door Alarms: There are auditory devices in place on all exit door or sliding glass doors of the facility. LPA observed them to be functioning properly.

Outdoor area: There is a sitting area in the backyard for residents to conduct outdoor activities. The backyard is fenced and there are no bodies of water. On one side of the facility there is no gate leading from the backyard to the front yard. On the other side of the facility there is a gate but it is not an emergency exit. The trash and recyclable bins are placed on the backyard of the side gate.

Smoke/Carbon Monoxide Detectors: At 10:10 a.m. LPA observed Administrator test the dual/hard wired smoke/carbon monoxide detectors. LPA observed them to be operational. A fire door leading to the bedrooms closed when detectors were tested.

LPA reviewed COMP III presentation with applicant.

Pre-Licensing is complete and this facility has no deficiencies. This report will be forwarded to the Centralized Application Bureau (CAB). The Applicant will be notified by the CAB Analyst when the facility license has been approved. Exit interview was conducted and a copy of the report was signed and provided to the Applicant.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC809 (FAS) - (06/04)

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