197610567-4-8-2024-31-AS-GSAO-D45SSQ-20240408140818

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610567
Report Date: 04/08/2024
Date Signed: 04/08/2024 02:09:12 PM

Document Has Been Signed on 04/08/2024 02:09 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:	SAINT MARIAM SENIOR CARE		FACILITY NUMBER:	197610567
ADMINISTRATOR:	HAYRAPETYAN, VIKTORYA		FACILITY TYPE:	740
ADDRESS:	18228 ACRE STREET		TELEPHONE:	(213) 476-2354
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY:	6	CENSUS: 0	DATE:	04/08/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Viktorya Hayrapetyan		TIME COMPLETED:	02:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 04/08/24, at 10:05am, Licensing Program Analyst (LPA), Gina Saucedo, conducted an announced visit to the facility for purpose of a pre-licensing evaluation. An application was submitted to Community Care Licensing Division-CCLD on 02/01/2024, Initial license for a Residential Care Facility for the Elderly (RCFE), 60 years and older. The requested capacity is for five (5) non-ambulatory and one (1) bedridden, total of up to six (6) residents but fire clearance only designated room # four (4) for bedridden use. Facility is a single-story home. Today's site visit consisted of LPA touring the physical plant at 10:25 AM inside and outside and observed the following: Bedrooms Staff: There is no bedroom designated for staff. Bedrooms Residents: There is a total of four (4) bedrooms. There shall be no more than two (2) clients per bedroom if used for non-ambulatory. Only one (1) is cleared for bedridden which is bedroom # 4 (four). There is three (3) other bedrooms in the house. One (1) of the bedrooms, bedroom # three (3) has a private bathroom. There are two (2) other bathrooms which proper grab bars and non-skid mats. All the bedrooms have proper bedding, chairs, nightstands, lamps in addition to overhead lighting. LIC 809C-continued

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2024

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: SAINT MARIAM SENIOR CARE	FACILITY NUMBER: 197610567
	VISIT DATE: 04/08/2024

NARRATIVE

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The dining/living room Resident & Staff Files:
There is enough seating for staff and residents. The furniture is in good condition. The resident/staff files will be kept in a tall, black cabinet along with the medication/first aid cabinet locked, secured and inaccessible to the residents.

Linens & Hygiene Supplies:
Adequate supply of linen stored in one (1) of the cabinets in the bathrooms and in one (1) of the pantries in the hallway.

Emergency Phone Numbers, Exit Plan & Menu:

The facility has a working phone number land line on the kitchen counter. Fire Extinguisher located in the kitchen on your right-hand side mounted on the wall. It is fully charged and has a date of 03/01/24.

Food Service:
Dishes, cups, and flat ware are stored in the kitchen cupboards, inspected and in good repair. Sharps are stored on your left-side of the kitchen locked and secured inaccessible to the residents two. Food supply adequate stored in several cabinets and consists of the following: canned goods, bottles of water, cereal, emergency buckets. The refrigerator, stove and microwave are in good condition and working.

Smoke Detectors:
There are smoke detectors/carbon monoxide through-out the house that were tested and work properly. They are hardwired and interconnected with the doors for an emergency.

Water Temperature:
The water temperature was tested for the bathrooms are they are within regulation:115.-116 Fahrenheit.

LIC 809C-continued

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2024

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: SAINT MARIAM SENIOR CARE	FACILITY NUMBER: 197610567
	VISIT DATE: 04/08/2024

NARRATIVE

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Pool/Jacuzzi:
There is no pool/jacuzzi in the facility.

Fire clearance:
Fire Clearance was approved on 03/11/2024 signed and dated.

Signal system:

The facility does have a signal system installed.

Administration:
The facility had submitted a Emergency and Disaster Plan For Residential Care Facilities For The Elderly and Infection plan. These signs are located at the entrance of the facility: Personal Rights of Residents, Rights of Resident by Council, Family Council, Infection Control, Emergency and Disaster Plan, Facility Sketch, Theft and Loss Policy, House Rules, Non-discrimination Policy and YES.

The Component III Orientation RCFE was shown to the Administrator.

Structure:
Overall Facility is a four (4) bedroom home with three (3) bathrooms, single-story home with two (2) outside ramps, there is no garage. The home does not have a fireplace which is covered in the dining area. There is one (1) washer and dryer located in the hallway which is locked and inaccessible to the residents. There are chemicals above the cabinets where the washer and dryer are located which are also locked, secured and inaccessible to the residents.

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

Exit interview conducted and copy of this report issued to the administrator.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2024

LIC809 (FAS) - (06/04)

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