197609819-8-26-2023-29-AS-SURA-CV3QKL-20230826121431

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609819
Report Date: 08/26/2023
Date Signed: 08/26/2023 12:15:19 PM

Document Has Been Signed on 08/26/2023 12:15 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:	NANA'S DREAM HOUSE FACILITY		FACILITY NUMBER:	197609819
ADMINISTRATOR:	BADALYAN, NAIRA		FACILITY TYPE:	740
ADDRESS:	7333 IRVINE AVE		TELEPHONE:	(818) 392-0843
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY: 6		CENSUS: 6	DATE:	08/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Naira Badalyan		TIME COMPLETED:	12:30 PM

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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility at 8:00 a.m., unannounced to conduct a required annual inspection. LPA Urena was greeted by staff, explained the reason for the visit. The Administrator Naira Badalyan arrived shortly after and explained the reason for the visit.

From 8:30 a.m. to 09:30 a.m., LPA Urena and administrator 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: Knives are stored in a locked box on the kitchen counter. Kitchen appliances were in operable condition. The facility has enough supply of perishable and non-perishable food. Freezer, and refrigerator are stocked with a variety of foods, fresh vegetables, and fruit. Emergency food supply is adequate for six residents, and two staff. First Aid kit is located in the kitchen area.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. One fire extinguisher was fully charged and was purchased on 05/2023. The LPA observed required postings throughout the common space. The hallway has a closet with extra linens.

BEDROOMS: Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are three bedrooms with double occupancy each bedroom.

BATHROOMS: Bathrooms were observed to be clean; shower area was in clean condition with grab bars and non-skid mat available. Paper towels were available for drying hands. Hand washing signs were displayed.

Continues on LIC 809C…

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2023

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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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: NANA'S DREAM HOUSE FACILITY	FACILITY NUMBER: 197609819
	VISIT DATE: 08/26/2023

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OUTDOOR SPACE: The LPA and staff observed the Outdoor space. A shaded patio area is available for residents to visit with family members. Side gate is unlocked.

RECORDS: Records review began at 11:00 a.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 11:45 a.m.; medications are centrally stored and locked in a cabinet in the kitchen area; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

The LPA obtained the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster

LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

No citations were issued at this time. Exit interview conducted. Signatures obtained. A copy of report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2023

LIC809 (FAS) - (06/04)

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