197609639-10-15-2024-29-AS-TBYE-DA3TYE-20241015150838

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609639
Report Date: 10/15/2024
Date Signed: 10/15/2024 03:09:37 PM

Document Has Been Signed on 10/15/2024 03:09 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:	ANA'S RESIDENCE CARE FACILITY		FACILITY NUMBER:	197609639
ADMINISTRATOR/ DIRECTOR:	ANNA ATAYAN		FACILITY TYPE:	740
ADDRESS:	7747 VAN NOORD AVE		TELEPHONE:	(323) 688-3377
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY: 6		CENSUS: 5	DATE:	10/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:59 AM
MET WITH:	Anna Atayan		TIME VISIT/ INSPECTION COMPLETED:	03:15 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 09:59 AM. LPA met with facility staff who contacted the facility administrator Anna Atayan. The administrator arrived to the facility at 10:22 AM. Entrance interview conducted and the reason for the visit was explained. Beginning at 10:23 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 drawer to contain knives and other sharp objects. LPA observed two (2) secured cabinets to contain resident medications and a first aid kit. The facility’s washer and dryer are located in the kitchen and a door to the garage was observed to be locked and inaccessible to clients in care. LPA observed a camera covering the kitchen area and entrance to the garage. LPA confirmed with the facility administrator that audio is not recorded. GARAGE: LPA observed the garage to be inaccessible to clients in care. The garage was observed to contain cleaning supplies, extra care supplies, emergency food and water supplies, an extra refrigerator, and a secured cabinet containing facility files. LPA observed the garage to contain a couch and a bed, the facility administrator confirmed that the garage doubles as a staff room. Continued on LIC 809C.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024

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: ANA'S RESIDENCE CARE FACILITY	FACILITY NUMBER: 197609639
	VISIT DATE: 10/15/2024

NARRATIVE

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OUTDOOR SPACE: The facility has one (1) emergency exit gate 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 storage for wheelchairs and extra care supplies. An outdoor deck was observed to be connected to the facility hallway and bedroom numbers four (4) and five (5). All railings on the deck were properly secured. LPA observed cameras in the outdoor spaces of the facility.

BEDROOMS: There are five (5) bedrooms in the facility; one (1) is a dual occupancy room and four (4) are single occupancy rooms. The garage is designated as a staff room. LPA and facility administrator toured all five (5) resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. One (1) resident bed was observed to contain full bed rails. Auditory alarms were observed on facility exits and all were functional at the time of the visit.

BATHROOMS: There are four (4) bathrooms at the facility. Three (3) bathrooms are designated as private resident bathrooms, and one (1) bathroom is designated as a shared resident bathroom. All resident bathrooms were observed to be clean and in good repair and were equipped with nonskid surfaces. Grab bars were observed in all resident showers and near all resident toilets, all were properly secured. The water temperature was measured between 106.5 and 117.1 degrees Fahrenheit, which is in compliance with regulation. LPA observed the shared resident bathroom to contain appropriately secured cabinets containing personal grooming supplies for resident use.

COMMON AREAS: This includes the living room, hallway, 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. LPA observed a fire extinguisher mounted in the living room to be fully charged and purchased on 01/11/2024. The living room contained adequate seating and activities for resident use. LPA observed a hallway closet to contain extra linens. The facility’s combination fire and carbon monoxide alarms, as well as the facility fire door, were tested at 12:44 PM and were functional at the time of the visit.

Continued on LIC 809C.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024

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: ANA'S RESIDENCE CARE FACILITY	FACILITY NUMBER: 197609639
	VISIT DATE: 10/15/2024

NARRATIVE

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RECORD REVIEW: Record review began at 10:50 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. Five (5) resident files were reviewed all resident files contained all required documentation and signatures. No deficiencies were observed during record review.

MEDICATION REVIEW: Medication review began at 12:04 PM. Medications for five (5) of five (5) residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review.

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 09/19/2024. 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 and two (2) staff members. The residents interviewed stated that the staff treat them well and are attentive to their needs. Both residents had no concerns with the facility. Both staff interviews were conducted with the assistance of the facility administrator acting as a translator. Both staff interviewed understood their roles 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 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: 10/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024

LIC809 (FAS) - (06/04)

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