197608760-10-1-2024-29-AS-TBYE-D9MUFX-20241001153329

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608760
Report Date: 10/01/2024
Date Signed: 10/01/2024 03:34:28 PM

Document Has Been Signed on 10/01/2024 03:34 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:	NOBLE CARE		FACILITY NUMBER:	197608760
ADMINISTRATOR/ DIRECTOR:	ARMINE TAGARYAN		FACILITY TYPE:	740
ADDRESS:	13300 ARMINTA STREET		TELEPHONE:	(818) 616-2427
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY: 6		CENSUS: 5	DATE:	10/01/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:58 PM
MET WITH:	Armine Tagaryan		TIME VISIT/ INSPECTION COMPLETED:	03:45 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 12:58 PM. LPA met with facility staff who contacted facility administrator Armine Tagaryan. Administrator arrived to the facility at 01:05 PM. Entrance interview conducted and the reason for the visit was explained. Beginning at 01:05 PM, 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 drawer to contain knives as well as a secured cabinet located under the sink which contained cleaning supplies. BEDROOMS: There are four (4) bedrooms in the facility; one (1) is a dual occupancy room and two (2) are single occupancy rooms. One (1) bedroom is designated as a staff room. LPA and facility administrator toured all three (3) resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Two (2) resident beds were observed to contain full bed rails. Auditory alarms were observed on facility exits and all were functional at the time of the visit. The staff room was observed to be locked and inaccessible to residents in care. Report Continued on LIC 809-C

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024

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: NOBLE CARE	FACILITY NUMBER: 197608760
	VISIT DATE: 10/01/2024

NARRATIVE

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Continued from LIC 809-C

BATHROOMS: There are three (3) bathrooms at the facility. Two bathrooms are designated as shared resident bathrooms, and one (1) bathroom is designated as a staff bathroom. Both resident bathrooms were observed to be clean and in good repair and were equipped with nonskid surfaces. Grab bars were observed in resident showers and near resident toilets, all were properly secured. The water temperature was measured between 108.7 and 114.4 degrees Fahrenheit, which is in compliance with regulation. The staff bathroom was observed to be clean and appliances were observed to be in good condition.

COMMON AREAS/GARAGE: This includes the living room and dining room. LPA observed the dining room to be clean and properly furnished at the time of the visit. The dining room contains a dining table with adequate seating for resident use. The living room was observed to be clean and in good repair. The living room contained adequate seating and activities for resident use. LPA observed a hallway closet to contain extra care supplies. LPA observed the garage to contain a washer and dryer, emergency water supplies, and extra care supplies. LPA observed cameras in the common areas of the facility, LPA confirmed with the administrator that audio is not recorded. The facility’s combination fire and carbon monoxide alarms were tested at 02:48 PM and were functional at the time of the visit.

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. LPA observed an appropriately fenced off pool that was inaccessible to residents in care.

RECORD REVIEW: Record review began at 01:47 PM. 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. Three (3) staff files were reviewed. All staff files contained the required documents and trainings. Five (5) resident files were reviewed all resident files contained all required documentation. No deficiencies were observed during record review.

Report Continued on LIC 809-C

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024

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: NOBLE CARE	FACILITY NUMBER: 197608760
	VISIT DATE: 10/01/2024

NARRATIVE

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Continued from LIC 809-C

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 conducted quarterly the facility’s last emergency disaster drill was conducted on 09/05/2024. 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 one (1) resident. the resident interviewed stated that the staff treat them well and are attentive to their needs. The resident had no concerns with the facility.

Due to time constraints LPA will return at a later date to conduct medication review and staff interviews. During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and liability insurance.

Exit interview conducted and copy of the report was issued.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024

LIC809 (FAS) - (06/04)

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