197610393-6-1-2023-31-AS-LQLY-CSDTHK-20230601144452

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610393
Report Date: 06/01/2023
Date Signed: 06/01/2023 02:45:37 PM

Document Has Been Signed on 06/01/2023 02:45 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:	NEASIS		FACILITY NUMBER:	197610393
ADMINISTRATOR:	GHAZRYAN, ANI		FACILITY TYPE:	740
ADDRESS:	8523 TERHUNE AVE		TELEPHONE:	(747) 250-9701
CITY:	SUN VALLEY	STATE: CA	ZIP CODE:	91352
CAPACITY:	6	CENSUS: 0	DATE:	06/01/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:47 AM
MET WITH:	Administrator Ani Ghazaryan		TIME COMPLETED:	02:50 PM

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Licensing Program Analyst (LPA) LaQueena Lacy arrived at the facility on 06/01/2023 at 10:47AM to conduct an announced Pre-Licensing visit and met with Administrator Ani Ghazaryan. Entrance Interview conducted with the administrator and explained the purpose of today’s visit, is to inspect the facility and ensure compliance with rules and regulations California Code of Regulations, Title 22, Division 6.

Today's site visit consisted of the LPA and administrator touring the physical plant at 11:02AM inside and outside the following was observed: The facility has one main entrance being used, there are required signage (Facility Exit Plan, Emergency/Disaster Contact information etc.) posted. The facility is a single-story building with five (05) bedroom and two (02) bathrooms. The facility fire clearance is granted for (05) non-ambulatory and one (01) bedridden resident. The facility temperature observed to be in range of 73 degrees Fahrenheit (F).

Kitchen: At 11:03AM LPA observed the kitchen to be clean and free from obstruction. Appliances observed

to be in good repair and functional. LPA observed sharps at 11:08AM to be stored and locked in a top drawer to the right of the stove inaccessible to resident by a magnetic lock. At 11:13AM LPA observed a bathroom and a storage room adjacent to the kitchen labeled employees only locked and inaccessible to resident to be the laundry area and storing toxins, and cleaning supplies clean and clear from debris or obstruction. LPA observed a closet near the kitchen to be storing the emergency food, dry food, canned goods, fruits, and vegetable. A fire extinguisher located on the wall in the kitchen to the left of the sink to have a purchase receipt from Home Depot dated 10/08/2022.

Bedrooms: At 11:23AM LPA inspected (05) bedrooms, bedroom number (02) is designated for the live in staff and storing extra linen and comforters. All bedrooms observed to be clean and appropriately furnished and equipped with adequate lighting and bedroom furniture.

Continued on LIC809C.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

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: NEASIS	FACILITY NUMBER: 197610393
	VISIT DATE: 06/01/2023

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Bedroom number three (03) is designated for a bedridden resident. Window and doors screens were observed during the time of inspection to be in good repair. Personal care items and emergency flashlights are stored in the night stand. Facility exit plan posted in each bedroom on the wall near the entrance.

Bathroom: At 11:38AM LPA observed (01) bathrooms to have non-skid mats and appropriate grab bars installed in shower and around toilet. At 11:43AM hot water was tested and measured in range of 109.8 degrees F. The telephone on premises is due for connection per the administrator on 06/01/2023 or 06/02/2023, the phone number currently being used is operational and functioning.

Medications: At 11:51AM the medication cupboard was observed to be locked and inaccessible to residents located in the office area. LPA observed the First Aid Kit and Manual stored in the medication cupboard at 11:56AM.

Living/dining room and common areas: A storage closet near the entrance of the facility labeled “employees only” storing incontinent supplies and PPE. The office area has a locked combination file cabinet which will be storing staff and residents’ files. The activities (puzzles, board games, arts and craft etc.) is located on a cupboard in the office area. At 11:58AM the common areas (living room, dining areas) were observed to be appropriately furnished and lighting is adequate and comfortable furniture for seating which was observed to be in good repair. The facility has a fire place observed to be locked and inaccessible to resident by a key lock. At 12:05PM the facility carbon monoxide/smoke detector alarms were tested and observed to be hardwired and interconnected to be operational and functioning properly. At 12:11PM LPA observed all exit doors to have auditory alarms, they were tested and observed to be operational and functioning properly. At 12:14PM LPA observed the outside and surrounding area of the facility to be clean and clear from debris and obstruction. The facility has a covered area with a table and chairs for lounging to be in good repair. The back yard exit gate is self-latching and functioning properly. No bodies of water observed on the property. The facility has surveillance cameras located inside and outside of the facility that will not be utilized, but have a ring camera at the front door. Component III was conducted with the licensee at 2:10PM. The facility is currently not in compliance with Title 22 Regulations at the time of the visit. During the time of the inspection, LPA observed (02) units behind the facility on the property that is not noted or included in the facility sketch. LPA observed these areas through the window and observed (01) unit being used for personal lodging with clothing hanging in the closet and personal items distributed around the room. The second unit appeared to be a storage area storing personal items. This report will be forwarded to the Centralized Application Bureau (CAB), once the units on the property have been determined the pre-license will be reviewed for approval.

Exit interview was conducted with Administrator Ani Ghazaryan and a copy of this report was provided.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC809 (FAS) - (06/04)

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