195850227-2-3-2023-29-AS-BBAI-CNPRBB-20230203115229

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850227
Report Date: 02/03/2023
Date Signed: 02/03/2023 11:52:42 AM

Document Has Been Signed on 02/03/2023 11:52 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:	AMERIHOME, INC		FACILITY NUMBER:	195850227
ADMINISTRATOR:	SARGSYAN, JASMINE H		FACILITY TYPE:	740
ADDRESS:	17019 MARLIN PL		TELEPHONE:	(818) 441-3590
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91406
CAPACITY: 6		CENSUS: 4	DATE:	02/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Jasmin Sargysan		TIME COMPLETED:	12:00 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 arrived at the facility unannounced to conduct a required annual. This annual had a specific emphasis on infection control practices and procedures. Upon arrival LPA met with Administrator Jasmin Sargsysan and explained the reason for the visit. At approximately 10:15am, 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. The carbon monoxide and smoke alarms were tested and all functioned properly. The fire extinguisher was fully charged and purchased in January 2023. LPA observed Kitchen to be clean and the appliances and fixtures functional. 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 (0F) and the refrigerator was maintained at 40F. Nonperishable food was observed to be adequate and located in cabinets next to the dining area. 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 at this time. Trash cans had tight fitting lids. There were (6) bedrooms total with (1) bedroom designated for staff use, which was located next to the dining area. LPA observed staff room to be empty at this time. All bedrooms for clients use were properly furnished and had appropriate bedding and linens. There are 3 bathrooms in the hallway. The resident bathroom(s) has a shower with non-skid materials. The toilet and showers have grab bars. The hot water temperature was tested in the bathrooms and the kitchen and was found to be within the range of 105F and 107.7F.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

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: AMERIHOME, INC	FACILITY NUMBER: 195850227
	VISIT DATE: 02/03/2023

NARRATIVE

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Continued from 809
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.

Laundry room was located near kitchen and was observed inaccessible to residents in care at this time. LPA observed cleaning supplies and detergent to be stored in locked cabinets above washer and dryer. Storage room was located near bedroom #1. LPA observed medication, resident files, first aid and PPE securely stored in this area. LPA also observed a sufficient supply of linen, towels and toiletries properly stored. Hallway closet near bedroom #4 was observed to store extra PPE and linen at this time.
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.

INFECTION CONTROL: During today’s visit, LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station. 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 has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate at this time.

Exit interview conducted and report issued to the Administrator.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

LIC809 (FAS) - (06/04)

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