195850306-12-14-2022-29-AS-ASMH-CM4QVM-20221214113033

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850306
Report Date: 12/14/2022
Date Signed: 12/14/2022 11:30:57 AM

Document Has Been Signed on 12/14/2022 11:30 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:	AAA JERUSALEM STARS		FACILITY NUMBER:	195850306
ADMINISTRATOR:	HCHERBA, SLAVA V		FACILITY TYPE:	740
ADDRESS:	5945 CAPISTRANO AVE		TELEPHONE:	(818) 888-1706
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY: 6		CENSUS: 6	DATE:	12/14/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Slava Hcherba and Kristina Adamyan		TIME COMPLETED:	11:00 AM

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) Ashley Smith conducted an announced pre-licensing visit at 9:00 a.m. The LPA met with applicants Slava Hcherba and Kristina Adamyan. This is a change of ownership application from AAA Jerusalem Star (197608939) to AAA Jerusalem Stars (#195850306). A Hospice Waiver has been requested. A fire clearance was approved on 11/15/2022 and all rooms were cleared for non-ambulatory residents, of which Bedroom #3 is permitted for bedridden persons only. Applicant successfully completed Component II on 11/22/2022 and Component III will be completed during today’s visit. Kitchen: Knives are stored in a locked drawer in the kitchen. The facility has a sufficient supply of perishable and nonperishable food. Additional food is located in the garage. There is an adequate supply of emergency food and water. The supply of dishes is adequate. Appliances were clean and all appeared functional. Kitchen, laundry and house cleaning supplies are stored in a locked cabinet in the kitchen and in the garage. Bedrooms: The facility has six bedrooms. Five rooms are designated for resident use. There are four private resident bedrooms (Rooms #1, 2, 4, 5) and one shared room (Room #3). Room #3, Room #4, and Room #5 have direct exits to the outside. Rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. Lighting in the rooms appeared adequate. Room #6 is a designated staff room. Bathrooms: There are four bathrooms, and out of the four bathrooms, one is designated as a staff bathroom. Restrooms are clean and sanitary with grab bars and non-skid surfaces. Rooms #3 and #5 have an attached bathroom. Restrooms were fully stocked. Hand-washing signs were observed in all restrooms. At 10:17 a.m., hot water temperature measured at 119.3 degrees F. Common areas: The common areas are appropriately furnished, and the lighting is adequate. Resident and staff records are stored in the staff area in the garage. There is not a fireplace in the living room.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022

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: AAA JERUSALEM STARS	FACILITY NUMBER: 195850306
	VISIT DATE: 12/14/2022

NARRATIVE

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Common areas (cont): Medications are stored in a locked closet near the entrance. Fire extinguishers were fully charged and serviced 2/2022. Smoke detectors and common monoxide detectors were tested at 9:30 a.m. and were operational at the time of the visit. There is a functioning telephone on the premises. Emergency exit plans are posted throughout the facility. Other required postings are near the front entrance.

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. There is a door w/gate with a self-latching mechanism for persons to enter the front yard. There is a locked storage shed in the back yard. There are no bodies of water on the premises at the present time. The garage is accessible from the house; the doors were locked. The washer and dryer are in the garage, along with the cleaning supplies.

Infection Control: The facility has a central entry point for symptom screening and sanitation station for staff, residents and visitors. The LPA was appropriately screened upon entry into the facility. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. Staff were wearing appropriate face coverings during the visit. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

Component III was completed during today’s visit.

Facility is in compliance with Title 22 Regulations at this time.

This report will be sent to the Centralized Application Bureau (CAB). The CAB Analyst will notify the applicant when the license has been approved. The applicant is aware that they are unable to operate under the new license number until they have been notified that the license has been approved by the CAB Analyst. Failure to comply could affect approval of the license.

Exit interview conducted and report issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022

LIC809 (FAS) - (06/04)

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