425850225-10-30-2024-29-AS-MRAN-DAJUQ2-20241030154625

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425850225
Report Date: 10/30/2024
Date Signed: 10/30/2024 03:46:31 PM

Document Has Been Signed on 10/30/2024 03:46 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	FAMILY CONNECT MEMORY CARE SOLVANG		FACILITY NUMBER:	425850225
ADMINISTRATOR/ DIRECTOR:	MAHAKIAN, LAUREN		FACILITY TYPE:	740
ADDRESS:	659 CHALK HILL ROAD		TELEPHONE:	(310) 383-1877
CITY:	SOLVANG	STATE: CA	ZIP CODE:	93463
CAPACITY: 6		CENSUS: 5	DATE:	10/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:30 PM
MET WITH:	Virgina Rodriguez and Lauren Mahakian		TIME VISIT/ INSPECTION COMPLETED:	04:00 PM

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Licensing Program Analyst (LPA) Rankin arrived at the facility unannounced to conduct a required annual visit at 1:30 p.m. When LPA arrived, there were two staff and five residents present. LPA was greeted by Staff and informed them of the reason for the visit. LPA met with Licensee Lauren Mahakian.

LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Knives are stored in a locked drawer in the kitchen. Kitchen appliances were in operable condition. The facility has a sufficient supply of food, including emergency food supplies.

Common areas: Living and dining room furniture were observed to be in good condition. The facility has Smoke detector(s) and carbon monoxide detector which are hard wired throughout the facility. There is a fireplace in the dining room, which is screened and inaccessible. LPA observed required postings throughout the common space. The fire extinguisher was charged and serviced 10/28/2024. The backyard has a covered outdoor area equipped with furniture for client use. Facility has open areas for visitors. No bodies of water noted.

Restrooms: The resident restrooms were clean and sanitary and in operating condition with non-skid stickers. The bathrooms were stocked with soap and paper towels.

Bedrooms: There are three (3) resident rooms, which were furnished as required. There is sufficient light for residents’ comfort.

Records: LPA reviewed resident and staff records. LPA reviewed five (5) resident files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, and current needs and services plan. All files were complete.

Continued on 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FAMILY CONNECT MEMORY CARE SOLVANG	FACILITY NUMBER: 425850225
	VISIT DATE: 10/30/2024

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LPA reviewed five (5) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, and current first aid certification. Files had all required documentation. All 1^st Aid certifications are up to date and annual training is done by hire date for each caregiver and is being updated based on that date. Initial training was filed for caregivers.

MEDICATIONS: A sampling of medication was reviewed. The medications are centrally stored and locked in a cabinet in the kitchen. Medications are labeled and doctor orders are found in the residents files.

PLANNED ACTIVITIES: LPA noted all residents, with the exception of one on hospice were out of their rooms and engaged in activities throughout the time of the visit. Residents participated in exercise on prior visit, and engaged in games and crafting during this visit.

INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient.

Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

LIC809 (FAS) - (06/04)

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