197610411-5-4-2023-31-AS-APAA-CRHR5L-20230504124319

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610411
Report Date: 05/04/2023
Date Signed: 05/04/2023 12:44:08 PM

Document Has Been Signed on 05/04/2023 12:44 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:	LOVING HOME FOR SENIORS		FACILITY NUMBER:	197610411
ADMINISTRATOR:	PODRUMYAN, MARO		FACILITY TYPE:	740
ADDRESS:	9652 QUARTZ AVENUE		TELEPHONE:	(424) 335-5222
CITY:	CHATSWORTH	STATE: CA	ZIP CODE:	91311
CAPACITY:	6	CENSUS: 3	DATE:	05/04/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Maro Podrumyan, Administrator		TIME COMPLETED:	12:40 PM

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At 10:00am, Licensing Program Analysts (LPA) Angela Panushkina conducted a Pre-License visit to this facility and met with Administrator, Maro Podrumyan. This is a Change of Ownership Application from facility license number #197610308 to #197610411. LPA conducted an entrance interview with the Administrator. At the time of this visit LPA observed and assessed three (3) residents present in the facility. All residents appeared to be clean and groomed. A Fire Clearance dated 03/01/2023 was received for six (6) residents, of which five (5) could be non-ambulatory residents, and one (1) bedridden in room #5. Facility has a hospice waiver for four (4) residents. The purpose of today’s visit is to inspect the facility to ensure compliance, under California Code of Regulations, Title 22, Division 6.

An emergency exit plan/sketch is posted by the entrance. The facility has a total of five (5) bedrooms, three (3) of which are private and one (1) shared room. Resident bedrooms were observed to be appropriately furnished. There are two (2) bathrooms in the facility designated for resident use and were observed to have non-skid mats and appropriate grab bars installed. At 10:15am, the hot water was tested and measured at 109.3°F. The facility will have awake staff at night and bedroom #1 is designated for staff use only.

The facility appeared to be clean, in good repair and kept at a comfortable temperature of 74°F. The common areas (living room, kitchen and dining areas) were appropriately furnished, and lighting was adequate. At 10:20am, LPA observed all kitchen knives in the kitchen drawer kept locked and inaccessible to residents in care. Appliances in the kitchen appeared to be functional. LPA observed sufficient supply of two days perishable foods and one week of non-perishable foods on premises. A fire extinguisher located in the kitchen was last serviced on 10/24/2022. At 10:30am, LPA observed resident and staff records with all medications were centrally stored in a locked closet located in a hallway. The first aid kit is readily available. Dual carbon monoxide and a smoke detector were located throughout the facility, and at 10:35am they were tested and observed to be operational. There is a functioning telephone on the premises.

Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

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: LOVING HOME FOR SENIORS	FACILITY NUMBER: 197610411
	VISIT DATE: 05/04/2023

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The necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on all doors and locked areas for centrally stored medications. Plan of operation for dementia residents was also discussed with the Administrator.

The attached garage is kept locked. The attached garage is currently being used for perishable and non-perishable food storage. The laundry area is located by the attached garage and at 10:50am LPA observed all detergents, cleaning supplies and other toxins are kept locked and inaccessible to residents in care.

At approximately 11:00am LPA toured the outside area of the facility. The facility has a swimming pool that is fenced all around with a gate and will be kept locked at all times. The fence surrounding the swimming pool is approximately 5 feet high all around its parameters. LPA also observed a clean covered patio and backyard furniture to accommodate the six (6) residents. LPA discussed the importance of maintaining care and supervision to meet the needs of residents.

Between 11:00am to 11:30am, LPA reviewed records of one (1) resident and one (1) staff. Resident and staff records appeared to be complete and updated.

Component III was conducted with the Administrator.

The facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) and be notified by the CAB Analyst when your license has been approved.

The exit interview was conducted with the Administrator and a copy of this report was signed and delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC809 (FAS) - (06/04)

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