<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880781
Report Date: 09/22/2021
Date Signed: 09/22/2021 11:36:11 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/22/2021 11:36 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:DIGNITY ADULT DAY CAREFACILITY NUMBER:
361880781
ADMINISTRATOR:KARAPETYAN, ALINAFACILITY TYPE:
775
ADDRESS:4110 HOLT BLVD, UNIT BTELEPHONE:
(818) 599-8998
CITY:MONTCLAIRSTATE: CAZIP CODE:
91763
CAPACITY: 50CENSUS: 0DATE:
09/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:13 AM
MET WITH:Alina KarapetyanTIME COMPLETED:
11:45 AM
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
Licensing Program Analyst (LPA) Anna Bueno made an unannounced visit to the facility for the purpose of conducting a required annual inspection, with an emphasis on infection control. LPA was screened at the front door by staff and was met by licensee Alina Karapetyan. Karapetyan explained that the building houses two programs: Adult Day Health Care (ADHC), licensed by Department of Health Care Services, and Adult Day Program (ADP). Karapetyan added that the front of the building is for ADHC while the entrance to ADP is in the back of the building. LPA Bueno observed the ADHC had clients present and in operation while ADP is not operational. Karapetyan phoned administrator Christine Campos who confirmed that the ADP has no clients as it is in the process of vendorization with Inland Regional Center (IRC).

During the inspection, LPA Bueno conducted a brief tour of the facility with Karapetyan. LPA observed that ADHC and ADP clients will be using the same restrooms and ADHC and ADP staff will commingle in the same kitchen and staff room/. This facility has submitted the LIC 808 mitigation plan which follows Community Care Licensing Division guidelines for COVID-19 testing, isolating/quarantining clients, and properly caring for clients with COVID-19 positive results and/or exposures. LPA observed that the facility adequate provisions of hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a 30+ day supply of Personal Protective Equipment (PPE). LPA Bueno also observed ADHC staff members are properly fitted with face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE. The facility has a plan in place

LPA Bueno observed no health and safety concerns at the time of visit. Based on observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted and a copy of this report was provided to Karapetyan.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2021
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 1