197610506-4-12-2024-31-AS-LDLC-D49M26-20240412091258

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610506
Report Date: 04/11/2024
Date Signed: 04/12/2024 09:13:11 AM

Document Has Been Signed on 04/12/2024 09:13 AM - 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:	BEST CARE ASSISTED LIVING ON HASKELL		FACILITY NUMBER:	197610506
ADMINISTRATOR:	GEVORKYAN, SONA		FACILITY TYPE:	740
ADDRESS:	9756 HASKELL AVE		TELEPHONE:	(310) 720-4551
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY:	6	CENSUS: 6	DATE:	04/11/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:38 AM
MET WITH:	Sona Gevorkyan- Administrator		TIME COMPLETED:	01:30 PM

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At 9:38am Licensing Program Analysts (LPAs), Leslie Ngo-Castaneda and Leizl De La Cerra conducted an announced pre-Licensing visit for a change of ownership to the above facility and met with Administrator, Sona Gevorkyan.

Fire Clearance was approved on 1/30/2024 for a maximum capacity of six (6) residents, of which six (6) Non-Ambulatory and one (1) bedridden residents in room #4; hospice for six (6).

The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. The facility is a single-story building. Today's site visit consisted of team touring the physical plant inside and outside and observed the following:

KITCHEN: The kitchen is equipped with a refrigerator, freezer, microwave oven and sink. At 10:34am, the team observed adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). All knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents.

FIRE EXTINGUISHER was last purchased on 1/30/2024 is located in the kitchen. First-aid is complete.

BEDROOMS: There are four (4) bedrooms designated for client use. All bedrooms are furnished with beds, dresser and required bedding and linen. Extra linen is available in the cabinet at the hallway. The bedrooms have sufficient closet space and have sufficient lighting. Auditory alarms were tested and observed to be operational. Facility will have awake staff. Bedroom #1 and bedroom #2 is for private use located at the left side of the hallway. Bedroom #3 and bedroom #4 is shared located at the right side of the hallway.

Continue to LIC 809-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: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

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: BEST CARE ASSISTED LIVING ON HASKELL	FACILITY NUMBER: 197610506
	VISIT DATE: 04/11/2024

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BATHROOMS: At 10:48am the team observed three (3) bathrooms are clean and in good repair. Properly supplied with toilet papers, soap, and paper towels. The hot water temperature measured between 117.5°F. observed appropriate grab bar and had non-skid mat. Bathroom #1 is located in the hallway beside the entrance of the facility. Bathroom #2 is located inside bedroom #3 for private use. Hot water for bathroom #2 measured at 117.2°F. Bathroom #3 is located inside bedroom #4 for private use. Hot water for bathroom #3 measured at 118.1°F.

COMMON AREAS: The facility maintains a comfortable temperature at 71°F. The living room and dining appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. Office is located beside the living room and exit to the patio.

MEDICATION: The medications will be kept in the kitchen cabinet and the team observed the cabinet kept locked and inaccessible to residents in care.

SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility. At 10:35am they were tested and observed to be operational.

SURROUNDING GROUNDS: In the back of the facility has sufficient yard space. LPAs observed appropriate outdoor furniture, with a covered shaded area for clients. The backyard is fenced. LPAs discussed the importance of maintaining the care and supervision to meet the needs of clients. There are no bodies of water. The driveway passageway and entrance to the home was clear of obstructions. All entry and exit doors have a functional auditory alert when the doors open.

GARAGE – there is a garage that is used as a storage and is blocked off to the residents. In addition, LPAs observed laundry room is located in the beside the kitchen. The washer/dryer appear to be in good condition. Laundry supplies are kept lock and inaccessible when not in use with supervision.

Component III was conducted with the administrator and licensee. 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. Exit interview was conducted and with a copy of this report was provided to the Applicant/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: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC809 (FAS) - (06/04)

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