195850278-9-9-2022-29-AS-TCAA-CJ4MV8-20220909095616

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850278
Report Date: 09/08/2022
Date Signed: 09/09/2022 10:17:00 AM

Document Has Been Signed on 09/09/2022 10:17 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:	LOVE IS US		FACILITY NUMBER:	195850278
ADMINISTRATOR:	GHAZARYAN, ANI		FACILITY TYPE:	740
ADDRESS:	7063 TYRONE AVE		TELEPHONE:	(818) 397-3456
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY: 6		CENSUS: 0	DATE:	09/08/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Ani Ghazaryan		TIME COMPLETED:	04:58 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) Teresa Camara conducted a pre-licensing visit to the above noted facility. The LPA met with applicant Ani Ghazaryan. This is a new facility. A dementia program was included in the plan of operation. A Hospice Waiver for six (6) has been requested. The facility is one-story. At 2:20 p.m., a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for five (5) non-ambulatory residents and one bedridden resident in room number three (3). The facility has three (3) double-occupancy resident bedrooms. Bedrooms number one (1) and two (2) do not have direct exits to the outside; bedroom number three (3) has an exit with a ramp. There is a fire door to the hallway. All resident rooms are set up with beds, night stands, lamps, closet organizers for folded clothes, chairs and closet space. The applicant must still purchase chest of drawers for each resident. The beds are furnished with spring bed bases, comfortable mattresses and clean linen; which includes, a mattress cover, 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. During the visit it was observed that in bedroom number three (3) the beds would need to be moved to allow easier access to the private bathroom. In addition, no bedroom was used as a passageway to another room, bath or toilet. There is no designated staff room, therefore awake night staff is required. All rooms were free of odors. All window screens were clean and maintained in good repair. There is a half bathroom in the hallway and each bedroom has a full bathroom for a total of three and a half bathrooms in this house. The resident bathrooms each have a shower with non-skid mats. The toilets 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 120F; with an average of 115.3*F.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

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: LOVE IS US	FACILITY NUMBER: 195850278
	VISIT DATE: 09/08/2022

NARRATIVE

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Resident and staff records are stored in a locked cabinet in the living room. Medications are centrally stored in a locked cabinet in the kitchen. The first aid supplies were complete, including a thermometer and a current version of a first aid manual which were stored on a shelf in the living room.

Kitchen knives are stored in a locked drawer in the kitchen. Stove burners are rendered inaccessible to the residents by removing them when not in use. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at negative three degrees Fahrenheit (-3*F) and the refrigerator was maintained at 37*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 under the sink. No flies or other vermin were observed.

The common areas were appropriately furnished, and the lighting was adequate. There is a television 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 non-private 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 inside the home. 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 detectors and carbon monoxide detectors were tested and functioned properly during the time of visit. There is one fire extinguisher located in the kitchen which appeared fully charged and does not exceed the expiration date.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

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: LOVE IS US	FACILITY NUMBER: 195850278
	VISIT DATE: 09/08/2022

NARRATIVE

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The laundry area is located behind closet doors in the hallway. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in bathroom cabinets. Extra incontinence supplies are stored in bathroom cabinets. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted at the front door and in each room. The emergency telephone numbers are posted in the living room along with other required postings.

The exterior passageways were clean and clear of any obstructions. There is a patio area with a table, chairs and umbrella for shade on one side of the house and an area with turf on the other side of the house. The entire property is fenced. There is a front gate to enter the property and once on the property there are no other gates. The front gate has a door handle type of self-latching mechanism and it remains unlocked at all times. This home is an accessory dwelling unit (ADU) which sits behind another home. The homes are separated by 6' fencing. Each home has a separate street address. There are no other buildings nor a garage on the premises and no bodies of water.

LPA conducted a Component III review with the applicant.

The following items must be corrected prior to licensure:

1. Move beds in bedroom #3 to allow access to the private bathroom and ensure the exit is not blocked.
2. Provide a chest of drawers for each resident in all bedrooms.

Submit proof of corrections (photos), along with a copy of this report, to LPA Camara, so that your application may be completed.

Exit interview conducted and report emailed to the applicant.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

LIC809 (FAS) - (06/04)

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