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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610406
Report Date: 05/18/2024
Date Signed: 05/18/2024 03:43:11 PM

Document Has Been Signed on 05/18/2024 03:43 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
Lookup Error,
, CA
FACILITY NAME:AMAZING ANGELSFACILITY NUMBER:
197610406
ADMINISTRATOR/
DIRECTOR:		WERDIAN, LUSINEFACILITY TYPE:
735
ADDRESS:14268 PIERCE STTELEPHONE:
(818) 455-9929
CITY:ARLETASTATE: CAZIP CODE:
91331
CAPACITY: 4CENSUS: 4DATE:
05/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:Armine Melkonyan - Back-up AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Armine Melkonyan, Back-up Administrator and Vanda Olehnovich, Direct Support Professional I & II (DSP I & II) and explained the purpose of the visit. The facility is licensed to care for (4) Developmentally Disabled Adults, ambulatory, ages 18 through 59. All clients residing at this Specialized facility receive case management services provided by North Los Angeles Regional Center. The facility is a level 3. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. The staff stated that they use disposable gloves to clean and disinfect the high touched surfaces in the common areas. The facility has submitted a COVID-19 Mitigation Plan and the Infection Control Plan. Staff are adhering to infection control requirements.
Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood, contains a total of (4) client bedrooms, (3) bathrooms, (1) staff bedroom, a living room, kitchen, dining area, backyard with shaded area, and attached garage. Currently, there are four (4) clients living in the facility. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, chair and sufficient closet space. Bathrooms have non-skid materials and hygiene supplies such as liquid soap and paper towels are available to clients. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and has a shaded area and sitting area. Laundry area is in the attached garage. There is (1) fire extinguisher mounted on the kitchen wall purchased on 01/03/2024. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Readings were 113.3 deg F in bathroom #1 and 113.5 deg. F in bathroom #2.
Operational Requirements: A current Plan of Operation was reviewed and the Infection Control Plan has been added to the Plan. Surety Bond in the amount of $5,000 is in effect. Liability insurance is valid and will expire on 10/19/2024. Last Fire Drill was conducted on 03/01/2024. *****REPORT CONTINUED ON LIC809-C*****
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2024
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
Lookup Error,
, CA
FACILITY NAME: AMAZING ANGELS
FACILITY NUMBER: 197610406
VISIT DATE: 05/18/2024
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Staffing: A total of five (5) staff members including the Administrator provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.
Personnel Records/Staff Training: Reviewed files for two (2) staff. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Back-up Administrator certificate expired on 03/25/2024 but renewal was submitted to CCL. Back up Administrator will provide a valid HIV/AIDS training to LPA by email.
Client Rights-Information: Client personal rights are posted. Per Administrator, facility provides internet services to all clients and have access to the facility phone. Administrator stated that (3) clients have cell phones and (2) have IPads. LPA interviewed (2) clients as the other (2) clients are out in the community.
Food Service: There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator (clean and well maintained). Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. One (1) client has a special diet.
Client Records-Incident Reports: LPA reviewed Client files for C1 through C4. Client files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.
Health Related Services: The medications are centrally stored and in their original containers. Medications were reviewed for C1-C4 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.
Incidental Medical Services: None of the clients at this home has a restricted health condition.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan. Emergency Intervention: Not-Applicable.

No deficiencies cited. An exit interview was conducted, and a copy of this report was provided to the Back-up Administrator, Armine Melkonyan.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2024
LIC809 (FAS) - (06/04)
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