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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850146
Report Date: 04/07/2022
Date Signed: 04/07/2022 11:06:45 AM

Document Has Been Signed on 04/07/2022 11:06 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:MY HOME OF AGINGFACILITY NUMBER:
195850146
ADMINISTRATOR:KYKHOSROWPOUR, VISHTASBFACILITY TYPE:
740
ADDRESS:23817 BESSEMER STREETTELEPHONE:
(818) 433-4592
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 6CENSUS: 0DATE:
04/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Vishtasb Kykhosrowpour-AdministratorTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a required Annual visit. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Vishtasb Kykhosrowpour and explained the reason for the visit. The administrator advised that there are currently no residents in the facility.

The LPA toured the physical plant areas inside and outside, with Vishtasb Kykhosrowpour at 9:25 a.m., to ensure there are no health and safety hazards.

BEDROOMS: There are (6) six bedrooms designated for resident use. Bedroom #1 has a direct exit to the exterior. The facility is capable of furnishing each room with clean linens, appropriate furnishings, and sufficient lighting for resident use.

RESTROOMS: There are (4) four bathrooms designated for resident use. (2) two bathrooms are located inside the resident bedrooms and (2) two are located in the hallway. Bathrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA advised the Administrators to ensure that bathrooms were stocked with paper towels and hand-washing signs prior to allowing resident admissions. Between 9:37 a.m. – 9:39 a.m., the LPA measured the hot water temperature in (2) two out (4) four bathrooms. The hot water temperatures measured between 117.6 and 119.9 degrees Fahrenheit.

Continued on LIC 809-C
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2022
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MY HOME OF AGING
FACILITY NUMBER: 195850146
VISIT DATE: 04/07/2022
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KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be properly stored and locked at time of visit. Hot water measured at 105.1 degrees Fahrenheit at 10:27 a.m.

COMMON SPACES: The common spaces included the living room; dining area and office area. The LPA observed cameras in all common spaces and exterior. All areas were clean, sanitary and in good repair. Smoke detectors are hardwired and interconnected, there is a Carbon Monoxide detector installed at the facility. All were tested at 9:42 a.m. and observed to be operational. The fire extinguisher was observed to be full and last bought on 04/5/21, the LPA advised the Administrator to ensure that fire extinguishers are serviced or purchased yearly. The LPA observed required postings in the entrance hallway.

BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. There is a pool on the property that was observed to be gated and locked at the time of the visit. The LPA observed a Laundry room which is located inside the attached garage. Laundry detergents, cleaning supplies, pesticides, and/or toxins are also stored in the garage/laundry area.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator Vishtasb Kykhosrowpour regarding the facility’s infection control practices. The Administrator was advised that they need to have upon entry, a central entry point for symptom screening, temperature checks, and sanitation station. The LPA also advised the Administrator to maintain a 30-day supply of Personal Protection Equipment (PPE). 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. Lastly, The LPA stated that they will send additional information via email in regard to signage to be posted around the facility.

No deficiencies were noted at this time. Exit interview conducted. A copy of the report and was provided via email.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC809 (FAS) - (06/04)
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