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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850075
Report Date: 10/11/2021
Date Signed: 10/11/2021 05:04:24 PM

Document Has Been Signed on 10/11/2021 05:04 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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:A-1 BOARDING CAREFACILITY NUMBER:
195850075
ADMINISTRATOR:HOVHANNES ISPIRYANFACILITY TYPE:
740
ADDRESS:6511 BONNER AVE.TELEPHONE:
(818) 691-3146
CITY:N. HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 6CENSUS: 6DATE:
10/11/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Gohar Shahinyan, DesigneeTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Salia Walker arrived at the facility unannounced to conduct a required Annual visit at 1:15 p.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Designee Gohar Shahinyan at 1:22 p.m. and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside, with the Gohar Shahinyan at 1:27 p.m., to ensure there are no health and safety hazards.
BEDROOMS: The LPA observed the resident bedrooms which were furnished with clean linens, appropriate furnishings, and sufficient lighting.
RESTROOMS: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap, paper products, and hand-washing signs in each restroom. Between 1:33 p.m. to 1:40 p.m., hot water temperatures measured between 113.5 and 117.8 degrees Fahrenheit in the common and private bathroom(s). At 1:28 p.m., the LPA observed there were accessible cleaning supplies and chemicals in common bathroom #1. The Designee secured it at the time of observation.
KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies in kitchen were observed to be properly stored and locked at time of visit. Hot water measured 116.8 Fahrenheit at 2:32 p.m. At 1:45 p.m., the LPA observed five (5) out of six (6) resident medications in kitchen cabinet were prepared for more than 24 Hours. The LPA advised the Designee that per Title 22 Regulation each resident's medication shall be stored in its originally received container, and no medications shall be transferred between containers. From 2:40 p.m. until 3:45 p.m., the LPA conducted a Medication assessment with Designee Gohar Shahinyan. All medication was counted for, and placed back into its original container.

Continue on LIC 809C..

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2021
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: A-1 BOARDING CARE
FACILITY NUMBER: 195850075
VISIT DATE: 10/11/2021
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COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed required postings in the hallway near the living room. One fire extinguisher was observed to be fully charged and purchased on 05/2021. The cabinets next entrance door contains additional nonperishable and perishable food items.

BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. The garage is detached to the facility. The garage is used as storage for addition supplies.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Designee regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed 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. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time and the LPA reviewed facility’s policies and procedures as it pertains to infection control.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/11/2021 05:04 PM - It Cannot Be Edited


Created By: Salia Walker On 10/11/2021 at 04:25 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: A-1 BOARDING CARE
FACILITY NUMBER: 195850075

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/11/2021
Section Cited

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87705 Care of Persons with Dementia: (f)The following shall be stored inaccessible to residents with dementia: (2)Over-the-counter medication.. alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
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Based on LPA's observations, the licensee did not comply with the section cited above, as cleaning supplies and disinfectants were found accessible in the facility's common restroom, which poses an immediate health and safety risk to persons in care.
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Type A
10/11/2021
Section Cited

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87465 Incidental Medical and Dental Care:(h)The following requirements shall apply to medications which are centrally stored: (5)Each resident's medication shall be stored in its originally received container..
This requirement is not met as evidenced by:
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Based on LPA's observation and medication assessment, the lincensee did not comply with the section cited above, as five (5) out of six (6) resident medications were removed from its original container and prepared for more than 24-Hours, which poses an immediate health and safety risk to persons in care.
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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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Salia Walker
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2021


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