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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850227
Report Date: 03/14/2022
Date Signed: 03/14/2022 01:47:14 PM

Document Has Been Signed on 03/14/2022 01:47 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:AMERIHOME, INCFACILITY NUMBER:
195850227
ADMINISTRATOR:SARGSYAN, JASMINE HFACILITY TYPE:
740
ADDRESS:17019 MARLIN PLTELEPHONE:
(818) 441-3590
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY: 6CENSUS: 0DATE:
03/14/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jasmine SargsyanTIME COMPLETED:
02:00 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 Analyst (LPA) Brian Balisi conducted a pre-licensing visit to the above noted facility. The LPA met with applicant, Jasmin Sargsyan. This is a new facility. A dementia program was included in the plan of operation. Hospice Waiver has been requested for (6) residents.

The facility is one story. At 10:15am, a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for (5) non-ambulatory residents; and, (1) of bedridden resident. The facility has (6) private resident bedrooms approved for Non- Ambulatory, Rooms #2 is also approved for (1) bed ridden resident. Resident rooms #1 , #2 and #3 have direct exits to the outside. All resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. Room # 6 is a designated staff room. All rooms were free of odors. All window screens were clean and maintained in good repair.

There are 3 bathrooms in the hallway. The resident bathroom(s) has a shower with non-skid materials. The toilet and shower have grab bars. The hot water temperature was tested in the bathrooms and the kitchen and was found to be within the range of 105*F and 107.7*F.

Resident and staff records are stored in filing cabinet which is currently located in office / storage room. Medications are centrally stored in a locked cabinet in the office / storage room as well. The first aid supplies were complete, including a thermometer and a current version of a first aid manual will be stored in the office/ storage room.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2022
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: AMERIHOME, INC
FACILITY NUMBER: 195850227
VISIT DATE: 03/14/2022
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
Continued from 809

Kitchen knives are stored in a locked drawer to the left of the dishwasher. Stove burners are rendered inaccessible to the residents by installing a lock when not in use. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in a locked cabinet located in office storage area. No flies or other vermin were observed.

The common areas were appropriately furnished, and the lighting was adequate. There are televisions and other entertainment equipment, games and/or activity supplies in the living room and dining area. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to nonprivate bathrooms. All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. There is no fireplace in the living room. Alarms on all exterior doors were engaged at the time of visit and functional. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included flashlights, or other battery powered lighting, and batteries. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit.

The facility smoke alarm system is hard wired. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. There are fire extinguishers throughout the house. They are fully charged and do not exceed the expiration date. The laundry area is located next to the kitchen. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in the office / storage area. . Extra incontinence supplies are stored in this area as well. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted throughout the facility. The emergency telephone numbers are posted in wall by kitchen. Other required postings are posted at this wall as well.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
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: AMERIHOME, INC
FACILITY NUMBER: 195850227
VISIT DATE: 03/14/2022
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
Continued from 809-C

The exterior passageways were clean and clear of any obstructions. There is a covered patio area at the back of the house with tables and chairs where residents can sit. The entire property is not fenced. The back and sides of the house are separated from the front yard by gates at the east and west side passageways. There is no gate on the driveway. There is a door w/gate with a self-latching mechanism for persons to enter the back yard. There are no other structures on the property. There are no bodies of water on the premises at the present time The garage is accessible from the house; the doors were locked.

Component III was completed in conjunction with the inspection.

No citations issued on a pre-licensing visit.

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.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3