195850176-8-23-2021-29-AS-SWAR-C66VFL-20210823162408

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850176
Report Date: 08/23/2021
Date Signed: 08/23/2021 04:25:25 PM

Document Has Been Signed on 08/23/2021 04:25 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	NOHO ASSISTED LIVING, INC		FACILITY NUMBER:	195850176
ADMINISTRATOR:	AYVAZYAN, ZHIRAYR		FACILITY TYPE:	740
ADDRESS:	6331 SIMPSON AVE		TELEPHONE:	(818) 404-0550
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY: 6		CENSUS: 0	DATE:	08/23/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:02 PM
MET WITH:	Zhirayr Ayvazyan, Administrator		TIME COMPLETED:	04:30 PM

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 Analysts (LPAs) Salia Walker and Sandra Urena conducted a pre-licensing visit to this property at 01:02 p.m., and met with applicant representatives Arpine Mkrtchyan and Zhirayr Ayvazyan. The applicant has obtained fire clearance for a total capacity of five (5) non-ambulatory residents, and one (1) bedridden resident for a total capacity of six (6) clients. The STD 850 Fire Safety Inspection Request form did not specify which room was assigned as bedridden, nor was it indicated on the facility sketch provided.

LPAs inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. At 01:20 p.m., all hard-wired smoke alarms and carbon monoxide detectors were tested and function properly. LPAs observed one fire extinguisher to be fully charged with a purchase 04/23/2021.

There are three (3) double occupancy bedrooms for resident use. There is no-live in staff bedroom. Facility must have 24-hour wake staff. Each bedroom is equipped with clean mattresses, pillows and bedding. There is sufficient supply of linens, including blankets, bath towels and wash cloths. Bedrooms have sufficient lighting. The facility has three (3) bathrooms for resident use. Resident bathrooms contained appropriate non-skid mats and grab bars. Bathrooms have sufficient paper products. Night-lights were present in the main hallway. Hot water measured 119.3 Fahrenheit at 01:41 p.m.

LPAs toured the kitchen area at 01:07 p.m. The facility has a (7) day supply of non-perishable food. Appliances and all equipment appear to be clean and in good repair. Kitchen knives are stored in a locked cabinet. The kitchen has a sufficient supply of plates, cups, cook ware and utensils with range inaccessible for residents with Dementia. Hot water measured at 118.3 Fahrenheit at 04:04 p.m.The living areas and dining areas are clean and properly furnished. All window screens and coverings are in good repair. Enough seating for the residents, all six (6), to sit at the same dining. A working telephone is present. There are activity supplies or will be activity supplies.

Continue on LIC809C..

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021

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 3

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: NOHO ASSISTED LIVING, INC	FACILITY NUMBER: 195850176
	VISIT DATE: 08/23/2021

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
26
27
28
29
30
31
32

Medications will be stored and locked in file cabinet. First aid kit was observed to have bandages, thermometer, scissors, tweezers and a current first aid manual. Facility records will be stored and locked in file cabinet. Cleaning and disinfectants are stored and inaccessible away in laundry room. Laundry room is located in the hallway. Laundry detergents and personal hygiene items are stored in a locked cabinet.
Garage: There is an adequate supply of emergency water, along with emergency nonperishable food items kept in the garage. There will be no firearms/ammunition stored on the property.

The facility has required postings, including emergency exit plan, Licensing Complaint Poster, Resident Personal Rights, Theft and Loss Policy, and Resident Council Rights.
Facility has one central entry point designated for universal screening. Alcohol-based hand sanitizer available upon entry. Signs are posted throughout the facility to promote handwashing, and cough/sneeze etiquette. Facility does not have an adequate 30-day supply of Personal Protection Equipment (PPE). LPAs will provide additional information on resources to obtain additional Personal Protection Equipment (PPE).

The exterior passageways were clean and clear of any obstructions. There are no bodies of water on the premises at the time of the visit. The LPAs observed the backyard, which has a covered outdoor area for resident use. There is a self-latching gate on the side of the house designated for an emergency exit. Physical plant is consistent with the submitted facility sketch/floor plan. With the exception of, indication as to which room will be utilized as the bedridden occupancy.

During today’s visit, LPAs reviewed facility’s program plan, personnel policies, abuse reporting procedures, in-service training protocol, and medication procedures.

During the inspection, the LPAs observed the following corrections needed prior to licensure:

Approval for Licensure is pending based on, clarification by Fire Department as to which room is approved/cleared for bedridden. Fire Department needs to submit a STD850 with clarification on which room is approved for one (1) bedridden. Also, the applicant needs to submit an updated Facility Sketch indicating which room was approved for one (1) bedridden client.

Continue on LIC809C..

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: NOHO ASSISTED LIVING, INC	FACILITY NUMBER: 195850176
	VISIT DATE: 08/23/2021

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
26
27
28
29
30
31
32

Comp III conducted.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

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

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3