195850285-1-15-2025-29-AS-ABAN-DCXVYD-20250115155059

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850285
Report Date: 01/15/2025
Date Signed: 01/15/2025 03:51:18 PM

Document Has Been Signed on 01/15/2025 03:51 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:	FALLBROOK ASSISTED LIVING		FACILITY NUMBER:	195850285
ADMINISTRATOR/ DIRECTOR:	ASATRYAN, YULIYA		FACILITY TYPE:	740
ADDRESS:	5504 FALLBROOK AVENUE		TELEPHONE:	(818) 713-0447
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY: 6		CENSUS: 5	DATE:	01/15/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:48 PM
MET WITH:	Yuliya Asatryan		TIME VISIT/ INSPECTION COMPLETED:	04:00 PM

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Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 01:48PM. LPA was greeted at the door by staff and Administrator Yuliya Asatryan. Entrance interview conducted.

At 01:50PM, the LPA along with 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.

BEDROOMS: There are six (6) bedrooms total of which four (4) are for single resident-use, one (1) is for shared resident-use, and one (1) is for staff-use. LPA observed resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

RESTROOMS: There are two (2) restrooms. Restrooms were clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. The restrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. At 01:57PM, hot water temperature was measured at 105.6 degrees F, which is within the required range.

KITCHEN: The LPA inspected the kitchen/food service area at 01:59PM. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable food. Food labels were inspected and checked for expiration dates and food labels had expiration date clearly marked. Knives and chemicals were locked inaccessible in kitchen drawer and under-the-sink cabinet. Fire extinguishers were fully charged and last serviced on 03/13/2024.

Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

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: FALLBROOK ASSISTED LIVING	FACILITY NUMBER: 195850285
	VISIT DATE: 01/15/2025

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OUTDOOR AREA: LPA observed the back and front patio which has areas for resident use. There is a self-closing and self-latching gate on the side of the house designated for an emergency exit. Passageways were free and clear from obstruction. There are no bodies of water on the premises. LPA observed the carport to contain a locked shed with a sufficient supply of non-perishable food, additional refrigerator/freezer, emergency water, and additional supplies.

COMMON AREAS: At the time of the visit, living room and family room furniture were observed to be in good condition. The facility maintained a comfortable temperature. At 02:09PM, smoke detector(s) and carbon monoxide detector were tested and were operational at the time of the visit. Auditory exit alarms were functioning at the time of the visit. LPA observed required postings throughout the common spaces. Laundry unit was observed in the hallway by the back of the property. Detergents were stored locked and inaccessible.

MEDICATION REVIEW: At 02:10PM, LPA reviewed medications for two (2) residents. Medications are centrally stored and locked in the kitchen. All medications including PRNs were labeled, stored, and locked inaccessible to residents. PRNs have physicians order on file. 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.

RECORD REVIEW: Beginning at 02:32PM, LPA reviewed five (5) out of five (5) resident files and two (2) personnel files for documents including but not limited to: medical records, care plans, resident Admission Agreement, TB test, health screening, staff training and fingerprint clearance. All resident and personnel files were in order. During the visit, LPA obtained copies of liability insurance, LIC 500, and resident roster.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPA reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency drills are conducted quarterly as is required, with the last drill conducted on 11/06/2024.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

LIC809 (FAS) - (06/04)

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