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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609546
Report Date: 11/01/2021
Date Signed: 11/01/2021 02:10:47 PM

Document Has Been Signed on 11/01/2021 02:10 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:HMS HOMEFACILITY NUMBER:
197609546
ADMINISTRATOR:DAVTIAN, ZHANNAFACILITY TYPE:
740
ADDRESS:14650 RUNNYMEDE STTELEPHONE:
(818) 640-4703
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY: 6CENSUS: 6DATE:
11/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Zhanna DavtianTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Ashley Smith arrived at the facility unannounced to conduct a required annual visit at 12:10 p.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Zhanna Davtian and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The dining room furniture was observed to be in good condition.

BEDROOMS: The LPAs observed the resident rooms, which were furnished appropriately with clean linens, furnishings and sufficient lighting.

RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Restrooms are sufficiently stocked with hand liquid soap and paper towels. The appropriate hand-washing signs were observed in the restrooms.

COMMON SPACES: In the common areas, walls, flooring and furniture were checked for cleanliness and were in good condition. There is a fireplace in the living room, which was screened and inaccessible. The garage is locked. There is a separate laundry area, yet disinfectants and detergents were kept locked and inaccessible. Required postings were observed in the entryway. All exits had a functioning auditory device. The backyard is equipped with furniture for resident use. There is fenced in-ground pool, which is kept locked and inaccessible. The facility is completely fenced in, with a self-latching gate on one side.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2021
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: HMS HOME
FACILITY NUMBER: 197609546
VISIT DATE: 11/01/2021
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INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. The LPA observed appropriate signage which promoted good hand hygiene, physical distancing, and symptoms of COVID-19. The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) in the garage and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. Staff were observed wearing face coverings. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

The LPA and Administrator discussed the recent PIN as it relates to visitation and staff vaccination requirements. No identified staffing concerns. The facility is in compliance regarding the requirements for indoor and outdoor visitation. This facility keeps track of vaccination rates for current staff. The facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies cited. Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021
LIC809 (FAS) - (06/04)
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