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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608756
Report Date: 08/22/2022
Date Signed: 08/22/2022 12:37:33 PM

Document Has Been Signed on 08/22/2022 12:37 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ANGEL LIFE CAREFACILITY NUMBER:
197608756
ADMINISTRATOR:LEVON CHALABYANFACILITY TYPE:
740
ADDRESS:407 ETON DRIVETELEPHONE:
(818) 478-1792
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY: 6CENSUS: 6DATE:
08/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:41 AM
MET WITH:Administrator, Michael PetrosianTIME COMPLETED:
12:45 PM
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Licensing Program Analysts (LPAs) Bennette Pena and Valeria Maldonado conducted an unannounced annual inspection focusing on the Infection Control Domain. Upon arrival LPAs were greeted and allowed entry by Caregivers, Lilit Avagyan and Anahit Zalinyan. The Administrator, Michael Petrosian was contacted by telephone (818) 416-4476 and arrived minutes later and explained the purpose of today's visit. Direct Support Professional (DSP) Harut Sargsian arrived shortly thereafter to assist with the tour. This home is licensed to serve Elderly residents age 60 and above, Developmentally Disabled, Level 4D, (6) Non-Ambulatory of which 6 may be Bedridden. The vendor is Frank D. Lanterman Regional Center. This home is approved for Hospice Waiver for 6. here were three (3) clients in care during the time of the visit and the other three (3) clients attended the day program. The Administrator certificate expires on 08/10/2023. The last fire/emergency disaster drill was conducted on 8/01/2022.

At 9:10 am, LPAs Pena, Maldonado and Administrator Michael Petrosian inspected the facility. This home is located in a residential neighborhood and contains 5 bedrooms, 2 bathrooms, living room, dining room, kitchen, and a detached garage.



Clients bedrooms were toured. Each of the 5 bedrooms has a bed, linen, dresser, light, and sufficient closet space, except for bedroom #4 which does not have a night stand. The Administrator stated that the client does not want a night stand in the room. Client breaks and throws it. The Administrator has an extra night stand available elsewhere that can be used in case another client comes in. Two (2) bathrooms have the required grabs bars and non-skid materials. The hot water in bathroom # 1 was 116.2 degrees and bathroom #2 was 115.2 which is within the required 105-120 degrees.

Client bedroom #2 (C1) bed was observed to be a Hospital bed with full-length bed rails. The required doctor’s order has been verified and it was issued on 4/26/2019 for the client.
The laundry room is clean and has cleaning supplies inaccessible to clients.

At 10:15 am, the kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and are working properly. Cleaning solutions and sharps were locked and inaccessible.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ANGEL LIFE CARE
FACILITY NUMBER: 197608756
VISIT DATE: 08/22/2022
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The common areas such as activity room and dining room are clean and have the required furniture. Exit doors have auditory devices that were operating at the time of the visit. There were fire extinguishers purchased on April 8, 2022 in the and kitchen and by the door leading to the backyard.

The backyard has a shaded area and sitting area. The activity area and backyard have been designated as the visitor area during the COVID-19 pandemic. LPAs observed that the gate leading outside has an unlocked/not functioning padlock. The Administrator immediately took it and threw it away. Administrator stated that he put it there to secure the gate because it was swinging. He already fixed the gate but forgot to remove the padlock.
There was a locked room next to the garage and when inspected, LPAs observed a lot of debris, broken bed mattresses and frames, ceiling was broken with dirty insulations coming out. The Administrator stated that the rain water caused the ceiling to give. He also stated that no one goes in there, but LPAs observed PPE supplies and clients' diapers stored inside.

Clients and Staff rosters were reviewed and clients’ medications were reviewed to confirm medication is given as prescribed and is documented properly.

NOTE: Infection Control Plan (ICP) was due June 30, 2022 and facility has submitted at the time of visit.

Pursuant to Title 22, deficiencies were cited on the attached 809D, exit interview conducted, and copy of the report and appeals rights were provided to the Administrator, Michael Petrosian.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022
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Document Has Been Signed on 08/22/2022 12:37 PM - It Cannot Be Edited


Created By: Bennette Pena On 08/22/2022 at 12:18 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ANGEL LIFE CARE
FACILITY NUMBER: 197608756

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in that the locked storage room has debris all over including broken bed frames, mattresses and ceiling was broken. The ceiling insulation was coming out and dropped all over the floor which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2022
Plan of Correction
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The Administrator contacted a roof man to fix the ceiling and clean the storage room. He will provide photos to CCLD/LPA Bennette Pena on or before the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Christine Yee
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2022


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