195850361-9-5-2024-29-AS-TBYE-D8TSVF-20240905141239

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850361
Report Date: 09/05/2024
Date Signed: 09/05/2024 03:01:09 PM

Document Has Been Signed on 09/05/2024 03:01 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:	MARY'S CHATEAU III		FACILITY NUMBER:	195850361
ADMINISTRATOR/ DIRECTOR:	PETIKYAN, MARY		FACILITY TYPE:	740
ADDRESS:	14835 WEDDINGTON ST		TELEPHONE:	(323) 333-8105
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91411
CAPACITY: 6		CENSUS: 6	DATE:	09/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:16 AM
MET WITH:	Mary Petikyan		TIME VISIT/ INSPECTION COMPLETED:	02:25 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) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:16 AM. LPA met with facility staff who contacted the facility administrator Mary Petikyan via telephone call. Facility administrator arrived to the facility at 09:32 AM Entrance interview conducted and the reason for the visit was explained. Beginning at 09:35 AM, the LPA, along with facility administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured drawer to contain knives as well as a secured cabinet located under the sink which contained cleaning supplies. The LPA observed fire extinguishers throughout the facility to be fully charged and purchased on 07/12/2024. BEDROOMS: There are six (6) bedrooms in the facility; all six (6) are single occupancy and all are designated for resident use. LPA and facility administrator toured all six (6) resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedroom number six (#6) is designated as the bedridden approved room and contains a direct exit to the front yard. One resident bed was observed to contain full bed rails. Auditory alarms were observed on facility exits and were functional at the time of the visit. LPA observed one (1) appropriately secured room, designated as a staff break room, to contain an extra refrigerator, an adequate supply of emergency water, and extra care supplies. Report Continued on LIC 809-C

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

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: MARY'S CHATEAU III	FACILITY NUMBER: 195850361
	VISIT DATE: 09/05/2024

NARRATIVE

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BATHROOMS: There are four (4) bathrooms at the facility. Three (3) bathrooms are designated as shared resident bathrooms and one (1) is designated as a private resident bathroom. All bathrooms were observed to be clean and in good repair and all were equipped with nonskid surfaces. Grab bars were observed in all showers and near all toilets, all were properly secured. The water temperature was measured between 106.3 and 110.1 degrees Fahrenheit, which is in compliance with regulation.

COMMON AREAS: This includes the living room, dining room, and a seating area. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contains an appropriately screened fireplace. Smoke detectors and carbon monoxide detectors were tested at 1:53 p.m. and were functional at the time of the visit. The dining room was observed to be clean and contains adequate seating for resident use. The seating room was observed to be clean with adequate seating. LPA observed a secured laundry room to contain a washer and dryer as well as detergents and cleaning supplies. LPA observed a hallway closet to contain an adequate amount of emergency food supplies.

OUTDOOR SPACE: The facility has two (2) emergency exit gates located in the front yard; LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. The backyard contains two (2) sheds that were observed to contain extra care supplies as well as extra walkers.

RECORD REVIEW: Record review began at 10:15 a.m. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, TB tests, consent forms, and personal rights. Six (6) staff files were reviewed. All staff files contained the required documents. Six (6) resident files were reviewed. All resident files reviewed contained all required documentation.

MEDICATION REVIEW: Medication review began at 11:25 a.m. Medications are stored centrally and securely in a cabinet in the seating room. Medications for three (3) residents were observed. All medications observed were documented appropriately on their centrally stored medication and destruction record sheets. No deficiencies were observed during medication review. Report Continued on LIC 809-C

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

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: MARY'S CHATEAU III	FACILITY NUMBER: 195850361
	VISIT DATE: 09/05/2024

NARRATIVE

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INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the
facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Last emergency disaster drill was conducted on 07/04/2024. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan were reviewed/updated on 07/01/2024 by the facility’s administrator.

INTERVIEWS: LPA interviewed two (2) staff and two (2) residents. All residents interviewed stated that the food was of good quality and is provided in sufficient amounts. All residents stated that staff treat them very well and are attentive to their needs. No residents interviewed had concerns with the facility. The staff members interviewed were knowledgeable on their roles and responsibilities, resident rights, the different forms of abuse and the appropriate reporting procedures for suspected abuse. One (1) staff interview was conducted with the assistance of the administrator acting as a translator.

During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and liability insurance.

No deficiencies were observed during today’s visit. Exit interview was conducted and a copy of today's report was issued.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

LIC809 (FAS) - (06/04)

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