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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609553
Report Date: 09/28/2023
Date Signed: 09/28/2023 03:43:46 PM

Document Has Been Signed on 09/28/2023 03:43 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:ANO TWO FACILITY FOR THE ELDERLYFACILITY NUMBER:
197609553
ADMINISTRATOR:CHAMCHYAN, NEKTARFACILITY TYPE:
740
ADDRESS:7905 STANSBURYTELEPHONE:
(818) 650-8140
CITY:PANORAMA CITYSTATE: CAZIP CODE:
91402
CAPACITY: 6CENSUS: 2DATE:
09/28/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Nektar Chamchyan, AdministratorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Annual Continuation at the facility today continuing the inspection that began on 08/23/2023. At 9:30 a.m., the LPA met with the Administrators and explained the reason for the visit.

RECORD REVIEW: At 10:20 a.m., the LPA reviewed resident records for two (2) out of two (2) residents. Resident records were reviewed for, but not limited to care plans, medical records, admissions agreement, and consent forms. All files were in order. At 11:15 a.m., the LPA conducted a personnel file review for all staff regularly scheduled and reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

At 2:48 p.m., the LPA conducted a review of medication and medication documentation with the Administrator for two (2) residents and observed that all medications were properly documented.

Copy of valid liability insurance and Facility Emergency Plan was provided to the LPA during the visit.

No deficiencies cited at this time. Exit interview conducted. A copy of the report of provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2023
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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