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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603652
Report Date: 08/27/2024
Date Signed: 08/27/2024 12:25:10 PM

Document Has Been Signed on 08/27/2024 12:25 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:1 DUARTE CAREFACILITY NUMBER:
198603652
ADMINISTRATOR/
DIRECTOR:		GASARDZHYAN, OVSEPFACILITY TYPE:
740
ADDRESS:2436 EL TORO ROADTELEPHONE:
(323) 697-4619
CITY:DUARTESTATE: CAZIP CODE:
91010
CAPACITY: 4CENSUS: 0DATE:
08/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Ovsep Gasardzhyan - AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Ovsep Gasardzhyan, - Administrator and explained the purpose of the visit. The facility is licensed to care for age range 60 and over, (4) ambulatory of which (4) may be non ambulatory. Facility has an approved hospice waiver for (4).
LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. Bathroom has hygiene items such as paper towel, hand soap and toilet paper.
Operational Requirements: A fire clearance is in place. Fire Drill has not been conducted with staff yet as there are (0) residents in the facility. Facility has working signal systems in exit points.
Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood which consists of (4) resident bedrooms, (2) bathrooms, living room, kitchen, dining area, laundry area in the outside, backyard with shaded patio area and (3) small storage sheds. Currently, there are zero (0) residents in the facility. Detached garage was converted to an ADU and was permitted. ADU has a separate entrance and address (633 Camino Real).The interior and exterior physical plant was inspected. Resident bedrooms were toured. Each bedroom has a smoke detector, linen, light, chair and sufficient closet space. LPA observed miscellaneous items such as metal ramp railing and extra disassembled storage. Administrator agreed to clear the area. Backyard was inspected and has a shaded area and sitting area. There is a camera in the back yard. There is (1) fire extinguisher in the facility which was last serviced on 09/01/2023. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Water temperature reading measured within the required 105 - 120 degrees Fahrenheit. At 9:50am, readings were 109.8 deg. F in bathroom #1 and 112.2 deg F in bathroom #2. *****REPORT CONTINUED ON LIC809-C*****
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2024
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: 1 DUARTE CARE
FACILITY NUMBER: 198603652
VISIT DATE: 08/27/2024
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Staffing: There are no staff except for the Administrator as the facility has zero (0) residents at the moment. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, and associated to the facility.
Personnel Records/Staff Training: Administrator's proof of health clearance, fingerprint clearance, vaccinations and 1st Aid/CPR training are current. Administrator's certificate expired on 04/19/2024 and proof of renewal submitted in April 2024 was provided to LPA.
Resident Rights-Information: Facility provides internet services to all residents and have access to the facility phone.
Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed.
Food Service: Administrator has emergency food supplies stored in the cabinet. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.
Resident Records-Incident Reports: No resident files reviewed during the visit.
Health Related Services: No medications reviewed during the visit. The facility will use the Medication Administration Record (MAR) log to document medications given. Medications will be stored in a locked cabinet in the hallway and inaccessible to residents. First-aid supplies along with a manual are maintainedin the facility.
Incidental Medical Services: There are no residents in the facility yet during the visit.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan. Emergency Intervention: Not-Applicable.


No deficiency cited, Technical Assistance issued.

Exit interview and a copy of this report was provided to the Administrator, Ovsep Gasardzhyan.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC809 (FAS) - (06/04)
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