195850373-10-3-2024-29-AS-TBYE-D9PSH5-20241003135258

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850373
Report Date: 10/03/2024
Date Signed: 10/03/2024 01:54:14 PM

Document Has Been Signed on 10/03/2024 01:54 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:	MSH SENIOR LIVING		FACILITY NUMBER:	195850373
ADMINISTRATOR/ DIRECTOR:	BADALYAN, NAIRA		FACILITY TYPE:	740
ADDRESS:	11556 VALERIO STREET		TELEPHONE:	(818) 565-9740
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY: 6		CENSUS: 4	DATE:	10/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:22 AM
MET WITH:	Naira Badalyan		TIME VISIT/ INSPECTION COMPLETED:	02:00 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 09:22 AM. LPA met with facility administrator Naira Badalyan. Entrance interview conducted and the reason for the visit was explained. Beginning at 09:24 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 appeared to be 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 lock box to contain knives as well as other sharp objects. OUTDOOR SPACE: The facility has two (2) emergency exit gates located on either side of the facility; LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. LPA observed an appropriately fenced off pool that was inaccessible to residents in care. COMMON AREAS: This includes the living room, staff office, and hallway. LPA observed the living room to be in good repair, clean, and properly furnished at the time of the visit. LPA observed the living room to contain an appropriately screened fireplace, activities for resident use, and two (2) couches. The living room also contains a dining table with adequate seating for resident use. LPA observed a camera in the living room and confirmed with the facility administrator that audio is not recorded. LPA observed a hallway closet to contain extra linens. Report Continued on LIC 809-C

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

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: MSH SENIOR LIVING	FACILITY NUMBER: 195850373
	VISIT DATE: 10/03/2024

NARRATIVE

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GARAGE: LPA observed functioning auditory alarms on the door to the garage. LPA observed the garage to contain a washer and dryer, emergency water and food supplies, and extra care supplies. LPA observed a secured drawer to contain cleaning supplies and laundry detergent. The facility’s combination fire and carbon monoxide alarms were tested at 01:31 PM and were functional at the time of the visit.

BEDROOMS: There are four (4) bedrooms in the facility; two (2) are dual occupancy rooms and two (2) are single occupancy rooms. LPA and facility administrator toured all four (4) resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Auditory alarms were observed on facility exits and all were functional at the time of the visit.

BATHROOMS: There are two (2) bathrooms at the facility. Both bathrooms are designated as shared resident bathrooms. Both resident bathrooms were observed to be clean and in good repair and were equipped with nonskid surfaces. Grab bars were observed in showers and near toilets, all were properly secured. The water temperature was measured between 108.1 and 110.5 degrees Fahrenheit, which is in compliance with regulation. LPA observed one secured cabinet under the bathroom sink to contain grooming supplies.

RECORD REVIEW: Record review began at 09:55 AM. 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, consent forms, and personal rights. Four (4) staff files were reviewed. All staff files contained the required documents and trainings. Four (4) resident files were reviewed all resident files contained all required documentation. No deficiencies were observed during record review.

MEDICATION REVIEW: Medication review began at 11:01 AM. LPA observed medications for four (4) of four (4) residents. All medications observed were documented properly 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: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

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: MSH SENIOR LIVING	FACILITY NUMBER: 195850373
	VISIT DATE: 10/03/2024

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. Emergency disaster drills are to be conducted quarterly; the facility’s last emergency disaster drill was conducted on 08/05/2024. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s administrator.

INTERVIEWS: LPA interviewed two (2) residents. Both residents interviewed stated that the staff treat them well and are attentive to their needs. Both residents had no concerns with the facility. LPA interviewed one (1) staff member. The staff interview was conducted with the assistance of the facility administrator acting as a translator. The staff interviewed was knowledgeable on their role and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse.

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

No deficiencies were observed during today’s inspection. Exit interview conducted and copy of the report was issued.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

LIC809 (FAS) - (06/04)

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