197610393-8-7-2024-31-AS-LDLC-D7X36L-20240807175831

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610393
Report Date: 07/30/2024
Date Signed: 08/07/2024 06:00:03 PM

Document Has Been Signed on 08/07/2024 06:00 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	NEASIS		FACILITY NUMBER:	197610393
ADMINISTRATOR:	GHAZARYAN, ANI		FACILITY TYPE:	740
ADDRESS:	8523 TERHUNE AVE		TELEPHONE:	(747) 250-9701
CITY:	SUN VALLEY	STATE: CA	ZIP CODE:	91352
CAPACITY:	6	CENSUS: 3	DATE:	07/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Gevorg Khaluyan, Licensee/Administrator		TIME COMPLETED:	03:30 PM

NARRATIVE

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Another LIC809 has been generated to reflect signatures that did not register or reflect on this report.
Licensing Program Analyst (LPA) Leizl de la Cerra conducted an unannounced required 1-yr inspection. LPA was allowed entry by Maria Durand, caregiver at 11:30am and explained the purpose of the visit. At 12:00pm, Gevorg Khaluyan, Administrator/Licensee arrived, LPA explained the purpose of the visit. LPA reviewed resident files, staff files and conducted a tour of the facility between 12:00pm to 3:00pm.

Outside: LPA toured the outside area. LPA observed a shaded sitting area for residents. There is a ramp access with sturdy hand railings. The facility does not have any bodies of water.

Common Area: LPA observed all furniture to be clean and in good repair. The facility maintains a comfortable temperature at 73 degrees Fahrenheit. The air conditioner is operational. The facility smoke alarm system is hard wired and interconnected. The facility uses a dual Carbon Monoxide/Smoke alarm detectors all over the common areas of the facility. Sprinkler systems are hardwired and interconnected. At 1:00pm they were tested and deemed operational. Facility maintains a telephone land line and it was observed to be operational. Required postings were observed. The fire extinguishers is located in the kitchen with purchase date of 04/26/2024.

Food Service and Kitchen Area: The kitchen appliances were functional. The kitchen has a working stove, faucet, refrigerator and microwave. LPA found enough food for at least three (3) days perishable and seven (7) days non-perishable which are properly stored. Knives were stored in a magnetic lock drawer. Food preparation areas are clean. Garbage can have a tight fitting cover. The laundry room which is inaccessible and locked is located near the kitchen area. There is a functioning washer and dryer. Laundry detergents and cleaning solutions were stored in the locked laundry room. Residents' dining table accommodates six (6) people.

Continued to LIC809-C

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Leizl De La Cerra	TELEPHONE: (818) 454-0632
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024

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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: NEASIS	FACILITY NUMBER: 197610393
	VISIT DATE: 07/30/2024

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Bedrooms: LPA observed all four (04) bedrooms to be properly furnished with appropriate dresser, night stand, chair, beddings and linens with sufficient lighting. Extra linens and beddings are stored in the hallway closet. Bedroom #1 is occupied currently by one (1) resident. Bedroom #2 is for staff use only, which remained locked. Bedroom #3 is occupied and shared by two (2) residents. Bedroom #4 is not currently occupied. Bedroom #5 is occupied by one (1) resident.

Bathrooms: LPA observed two (02) bathrooms at the facility, one (01) is for residents to use and one (01) is for staff use only which is kept locked. Resident bathrooms have hand washing signs, soap and paper towels. Proper grab bars and non-slip bath mats. The water temperature in the resident bathroom is 112.7 degrees Fahrenheit.

Personnel Records/Staffing: LPA Reviewed files for four (4) staff members. Files are maintained at the facility in a locked 4 drawer cabinet. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current for two (2) staff members. Staff employed all have criminal background clearance, fingerprint cleared and associated to the facility. LPA observed two (2) caregivers S1 and S2, 1st Aid/CPR certification were expired.

Residents Records: LPA reviewed files for four (04) out of four (04) residents. Files are maintained at the facility in a locked 4 drawer cabinet. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, and Admission agreements, Medical/Functional assessments, Needs and Services Plans, Personal rights. Medications were reviewed for one (01) resident to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubbled packed. Medications are in a locked cabinet

The First Aid Kit is complete and current.

Deficiency issued. An exit interview was conducted, and a copy of this report was provided to licensee/administrator.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Leizl De La Cerra	TELEPHONE: (818) 454-0632
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/07/2024 06:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: NEASIS	FACILITY NUMBER: 197610393
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in three (3) out of five (5) staff member which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/06/2024
	Plan of Correction
1 2 3 4	Licensee will make sure to have a staff with CPR and First Aid training on duty and on the premises at all times. Licensee will provide a copy of CPR/First Aid certification for all three (3) staff by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Leizl De La Cerra	TELEPHONE: (818) 454-0632
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024

LIC809 (FAS) - (06/04)

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