195850278-9-13-2024-29-AS-EMOY-D93MNX-20240913094613

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850278
Report Date: 09/12/2024
Date Signed: 09/13/2024 09:47:27 AM

Document Has Been Signed on 09/13/2024 09:47 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	LOVE IS US		FACILITY NUMBER:	195850278
ADMINISTRATOR/ DIRECTOR:	GHAZARYAN, ANI		FACILITY TYPE:	740
ADDRESS:	7063 TYRONE AVE		TELEPHONE:	(818) 397-3456
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY: 6		CENSUS: 6	DATE:	09/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	ANI GHAZARYAN		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

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Licensing Program Analysts (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 10:02 a.m. Upon arrival, LPA Mosley was greeted by staff and administrator and inform them of the visit. The LPA met with Administrator ANI GHAZARYAN and explained the reason for the visit. The 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 facility is a single-story family home located in the back of the property consisting of 2 homes. The home consists of a living room, dining room, a kitchen, three (3) resident shared bedrooms, three (3) bathrooms, and a private staff / guest half bathroom/ common powder room. The entry way to the back house is separated from the front house, which has a separate address, and separated by a solid fence. The facility is fire cleared for 5 NON-AMBULATORY and 1 BEDRIDDEN resident.

RESTROOMS: The three (3) resident restrooms and a half restroom /powder room were clean, sanitary and in operating condition with grab bars and non-skid surfaces. The restrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured between 10:10 a.m.to 10:26 a.m.; the first bathroom measured at 107.3 degrees Fahrenheit at 10:10 a.m, the second bathroom measured at 110.9 degrees Fahrenheit at 10:15 a.m the third bathroom measured 110.8 at 10:26 a.m. all within the required range.

BEDROOMS: There are three (3) total bedrooms in the facility; all three (3) are designated as shared rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

Report Continued on LIC 809C...

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

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: LOVE IS US	FACILITY NUMBER: 195850278
	VISIT DATE: 09/12/2024

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Report Continued from LIC 809...

KITCHEN: The LPA inspected the kitchen/food service area at 10:28 a.m. Knives and sharps were observed in a locked cabinet. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 115.6 degrees Fahrenheit at 10:32 a.m.

COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 1:03 p.m., smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was observed, fully charged and purchased on 4/20/2024. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 07/15/2024 and are conducted quarterly. Activities were observed in the common areas.

GARAGE /FRONT YARD/ BACKYARD: The garage is attached to the main home and is maintained locked at all times. There is a washer and dryer on the premises that is locked at all times. Laundry detergent was observed in the locked washer and dryer area. LPA observed an adequate amount of emergency food, water, and cleaning supplies that are kept in a locked shed inaccessible to residents in care. The shed is located at the front yard. The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. LPAs observed one (1) self-latching gate. There were no bodies of water noted at the time of the visit.

RECORDS :Resident Records were reviewed beginning at 10:41 a.m. and Personnel records at 11:42 a.m. Six (6) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan.

Report Continued on LIC 809C..

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

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: LOVE IS US	FACILITY NUMBER: 195850278
	VISIT DATE: 09/12/2024

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Report Continued from LIC 809C...

Five (5) personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order.

MEDICATIONS: Medications review began at approximately 3:15 p.m. The medications are locked in a cabinet in the kitchen. Medications for six (6) residents were reviewed. Medications reviewed were found to be self administered as prescribed and documented on the centrally stored medication and destruction records.

INTERVIEWS: Two (2) staff interviews were conducted. Six (6) resident interviews were attempted. Two (2) resident interviews were conducted. Interviews were conducted between 4:00 p.m. to 4:30 p.m.

Administrator was informed that Licensing fees are due this month on September 27th. Administrator was given information on how to pay online.

No deficiencies were cited during today’s inspection. Exit interview conducted.

Due to technical difficulties with the system a copy of the report was emailed to the Administrator for signature. A hard copy with the administrators signature will be in the physical file and e-file.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

LIC809 (FAS) - (06/04)

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