198601684-5-20-2022-31-AS-JGTN-CELRBP-20220520125304

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601684
Report Date: 05/20/2022
Date Signed: 05/20/2022 12:53:30 PM

Document Has Been Signed on 05/20/2022 12:53 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:	VALLEY VILLAGE LARKSPUR HOUSE		FACILITY NUMBER:	198601684
ADMINISTRATOR:	ALEXANDER KRASNOSHTEIN		FACILITY TYPE:	734
ADDRESS:	15255 LARKSPUR STREET		TELEPHONE:	(818) 587-9450
CITY:	SYLMAR	STATE: CA	ZIP CODE:	91342
CAPACITY: 5		CENSUS: 4	DATE:	05/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Alex Krashnoshtein - Administrator		TIME COMPLETED:	01:00 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	A Required One (1) year - Infection Control visit was conducted today by Licensing Program Analyst (LPA) Gary Tan and Deputy Director (DD) Kevin Gaines. LPA and DD met with Administrator Alex Krashnoshtein. Purpose of visit was stated. LPA observed that the four (4) residents were at the facility during visit. This facility is licensed as an Adult Residential Facility for Persons with Special Healthcare Needs (ARFPSHN) vendored by Northern Los Angeles Regional Center (NLARC) and Lanterman Regional Center (LRC). A tour of the physical plant was conducted at 11:15 AM and the following was noted: The garage entrance is the only entrance being utilized at the facility, there is a sign at the main door to use the garage for entrance and screening. There is a sign on the garage door that everyone entering at the facility must be screened. Screening area is located immediately and hand washing is required upon entry. Sign in sheet, hand sanitizer, gloves and masks are available. LPA and DD was screened upon entry. All staff were observed to be wearing mask. The facility had submitted and approved Mitigation plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with cover. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room. (continued to LIC 809-C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

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: VALLEY VILLAGE LARKSPUR HOUSE	FACILITY NUMBER: 198601684
	VISIT DATE: 05/20/2022

NARRATIVE

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(continued from LIC 809)

LPA and DD toured the facility with the administrator. LPA and DD observed six (6) staff members (including the administrator) on duty providing care and supervision to the clients during today's visit. There are five (5) private bedrooms and all are equipped with a special lift installed to assist clients to transfer to/from their bed. All bedrooms were also observed to be fully furnished and maintained appropriately. There are two (2) bathrooms; one bathroom was equipped with a special lift. The living room, dining area/activity room, kitchen area, medication area, laundry room, and garage were inspected and observed to be clean. Laundry detergent however, was observed at 11: 43 AM in the laundry room accessible to clients. Medications are kept in locked cabinet in the kitchen area. Cleaning supplies and other toxins were observed to be locked and inaccessible to clients. Clean linens were in adequate supply. Hot water was measured at a range of 114.8°F to 115.5°F. Outdoor area was also observed for safety. There was no body of water at the facility. Facility has 4 (four) fire extinguishers and all were observed to be operational and last serviced on 07/08/21. Fire drill was last conducted on 06/02/21.

Citation issued. Appeal rights discussed and given.

Exit interview was conducted and copy of this report was issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/20/2022 12:53 PM - It Cannot Be Edited

Created By: Jose Gary Tan On 05/20/2022 at 12:21 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALLEY VILLAGE LARKSPUR HOUSE	FACILITY NUMBER: 198601684
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in leaving the laundry detergent accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/27/2022
	Plan of Correction
1 2 3 4	The administrator immediately kept the laundry soap in the locked cabinet and agreed to remind all staff to keep all toxins in locked cabinet and will submit proof of attendance/communication/in service to CCL on or before the POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Naira Margaryan

LICENSING EVALUATOR NAME:

Jose Gary Tan

LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

LIC809 (FAS) - (06/04)

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