195850227-3-12-2025-29-AS-SURA-DEPSCQ-20250312134556

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850227
Report Date: 03/12/2025
Date Signed: 03/12/2025 01:47:13 PM

Document Has Been Signed on 03/12/2025 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	AMERIHOME, INC		FACILITY NUMBER:	195850227
ADMINISTRATOR/ DIRECTOR:	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: 5	DATE:	03/12/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Jasmine Sargsyan		TIME VISIT/ INSPECTION COMPLETED:	01:45 PM

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Licensing Program Analyst (LPA) Sandra Urena and Quoc Huynh arrived at the facility unannounced to conduct a required annual inspection. The LPAs were greeted by staff and informed them of the reason for the visit. The staff contacted the Administrator to inform them of the visit. The Administrator Jasmin Sargsyan arrived shortly thereafter.

The LPA and the Administrator 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.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature of 76 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The two (2) fire extinguishers were fully charged and were last serviced 2/7/2025. The LPAs observed required postings throughout the common space.

KITCHEN: Knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The hot water temperature measured at 114.1 degrees Fahrenheit.

BEDROOMS: Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are three designated client rooms and one staff room. There was a linen closet in the hallway with extra towels and linens.

BATHROOMS: Bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. Handwashing signs were posted. The hot water temperature measured in the restrooms at 115.1 degrees Fahrenheit.

Continues on LIC 809C...

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMERIHOME, INC	FACILITY NUMBER: 195850227
	VISIT DATE: 03/12/2025

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OUTDOOR AREA: The backyard has a shaded area with outdoor furniture No bodies of water noted. The washer and dryer are in a room adjacent to the kitchen. All cleaning liquids and materials are locked in a cabinet above the washer and dryer.

RECORDS: Records review began at 11:30 a.m., Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 12:41p.m. Medications are centrally stored and locked in the medication room; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

INFECTION CONTROL: The facility has 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 LPA reviewed the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster
- Certificate of Liability
- Emergency Drills

No citations were issued. Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025

LIC809 (FAS) - (06/04)

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