197610392-7-16-2024-31-AS-JGTN-D793T9-20240716183135

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610392
Report Date: 07/16/2024
Date Signed: 07/16/2024 06:32:06 PM

Document Has Been Signed on 07/16/2024 06:32 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
WOODLAND HILLS S.ASC, 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: 4	DATE:	07/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:05 PM
MET WITH:	Liana Avanesyan - Administrator		TIME COMPLETED:	06:30 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	Licensing Program Analyst (LPA) Gary Tan met with Administrator Liana Avanesyan for a one (1) year required visit for this facility. Purpose of the visit was stated. There is only one entrance being utilized at the facility. Screening area is located about ten (10) feet upon entrance by the living room. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation and Infection Plan. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. A tour of the physical plant was conducted with the Administrator at 3:25 PM. The facility has three (3) bedrooms and two (2) bathrooms currently occupying four (4) residents. The facility is fire cleared for six (6) non-ambulatory residents, one of which maybe bedridden in Room #2. Hospice waiver for six (6) residents. Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, the following was noted: Living and dining room furniture were also checked. The living room is neat and clean along with the dining room. The facility maintains a comfortable temperature at 77°F. Dual smoke/carbon monoxide detector is hardwired, tested and observed to be operational. There was a fire extinguisher located in the kitchen area. Fire extinguisher was observed to be full and last bought on 07/16/24. The backyard of the facility has outdoor furniture, with a covered shaded area for clients. There is no body of water in the facility. (continued to LIC 809)

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: JUDD ASSISTED LIVING	FACILITY NUMBER: 197610392
	VISIT DATE: 07/16/2024

NARRATIVE

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(continued from LIC 809-C)

The garage is detached to the home and being used as storage for frozen and emergency food, old equipment, and PPE. The garage was observed to be locked and inaccessible to residents. Laundry is in the kitchen. Laundry detergents, cleaning solutions and other chemicals and toxins are locked and secured in the garage.

Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Dishwashing liquids and other cleaning supplies were stored in the garage. All sharps and knives were also observed to be locked in the medication cabinet.

The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageway are lit to non-private rooms. Clients have sufficient amounts of personal hygiene product which is provided by the licensee. Staff Room: Staff room is observed to be locked. No medications are observed in the staff room. The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. The hot water temperature measured at 109.2°F. Towels and washcloths are not shared. There is enough clean linen available in stock at the cabinet.

Medications: LPA observed medication in a locked kitchen cabinet and inaccessible to residents. Medications are listed on the centrally stored medication and destruction record. There is a complete first aid kit located in the medication cabinet.

Client records: Client records are reviewed and appeared to be complete and updated. Staff records: LPA also conducted a complete file review of staff records. Staff record appeared to be complete and updated.

Disaster drill was last conducted on 07/09/24. Required posting are observed to be complete and current and displayed properly at the facility.

Exit interview conducted and copy of this report issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

LIC809 (FAS) - (06/04)

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