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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610556
Report Date: 06/19/2024
Date Signed: 06/19/2024 12:01:15 PM

Document Has Been Signed on 06/19/2024 12:01 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:INGOMAR ASSISTED LIVINGFACILITY NUMBER:
197610556
ADMINISTRATOR/
DIRECTOR:		BAREGHAMYAN, ELENFACILITY TYPE:
740
ADDRESS:19000 INGOMAR STREETTELEPHONE:
(818) 403-1803
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 6CENSUS: 0DATE:
06/19/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Yegeyan Nazar-LicenseeTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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At 10:00am Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted an announced Pre-Licensing Inspection and met with the facility administrator Elen Bareghamyan and Licensee Yegeyan Nazar.

An application was submitted to Community Care Licensing Division-CCLD on 12/29/2023, Initial license for a Residential Care Facility for the Elderly, 60 years and older. A fire clearance was approved on March 29, 2024 for five (5) non-ambulatory residents and one (1) bedridden resident, for a total capacity of six (6). The bedridden fire clearance is for any bedroom. Bedrooms #1, #2, #3, #4, #5, cleared for non-ambulatory residents. The applicant also requested a hospice waiver and granted for four (4) residents. The facility is a single-story home.
A tour of the physical plant was initiated at approximately 10:15am and the following was observed:

KITCHEN: The facility has a kitchen area that is equipped with a refrigerator, microwave oven and sink. There were adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). Knives and sharps were observed to be locked in a kitchen drawer and inaccessible.

BEDROOMS: There are six (6) bedrooms designated for residents’ private use. All bedrooms are furnished and well equipped with beds, night-stand, chair, dresser, bedding, and extra linen. Rooms were observed to have sufficient lighting and closet space. Auditory alarms were tested and observed to be operational at 10:30am. Facility will have an awake staff.

BATHROOMS: The facility has six (6) bathrooms, bathrooms #3 and #4 are designated for staff and residents’ family members use. All bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured at 10:40am to be at 110°F degrees.

Continue on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: INGOMAR ASSISTED LIVING
FACILITY NUMBER: 197610556
VISIT DATE: 06/19/2024
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MEDICATION: LPA observed medications and facility staff/resident files will be kept locked in the cabinet which is located in the separate office are next to the living/family room. The First-Aid kit with current edition of first-aid manual is also located in the locked cabinet. LPA observed the kit to be new. The cabinet is inaccessible to residents in care. Only employees responsible for the centrally stored medication will have access to the medication. Facility has Dementia Care Program. Emergency call buttons are available and will be provided to residents.

SMOKE DETECTORS/CARBON MONOXIDE. The smoke detectors and carbon monoxide are hard wired, inter-connected and were located throughout the facility. At 11:00am they were tested and observed to be operational. The facility has one (1) new fire extinguisher that was purchased on May 21, 2024. The fire extinguisher is located in the kitchen area.

COMMON AREAS: The facility maintains a comfortable temperature at 73°F. The living room and dining appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. LPA observed puzzles, books, balls, and board games to provide activities to residents in care. The Facility has landline, LPA checked at 11:05 to be operational. LPA observed laundry room is located in the separate closed area between kitchen and bedrooms. The washer/dryer appear to be new and in good condition. Laundry supplies and other chemicals are kept locked inaccessible in the storage room, with supervision when not in use.

SURROUNDING GROUNDS: In the back of the facility has sufficient yard space. LPA observed appropriate outdoor furniture, with covered shaded area for residents. The backyard is fenced. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients. There are no bodies of water.

GARAGE: The garage is currently being used for storage and additional supplies for residents. The LPA observed the garage locked and not accessible to residents in care.

Component III was conducted with the Administrator.

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

Exit interview was conducted and a copy of this report was provided to the Applicant/Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC809 (FAS) - (06/04)
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