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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609824
Report Date: 07/02/2021
Date Signed: 07/02/2021 11:42:25 AM

Document Has Been Signed on 07/02/2021 11:42 AM - 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:ASHLEY'S GARDEN ELDERLY CAREFACILITY NUMBER:
197609824
ADMINISTRATOR:OSBORN, ANNIEFACILITY TYPE:
740
ADDRESS:7930 RHODES AVETELEPHONE:
(818) 642-0907
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 5DATE:
07/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Asmik ArzuyanTIME COMPLETED:
12:00 PM
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At 8:30 am Licensing Program Analyst (LPA) Sandra Urena conducted Infection Control call, and asked infection control questions before arriving at the facility. At 8:45am LPA was greeted by Caregiver. Administrator arrived at around 9:30am. LPA introduced herself and explained the reason for the visit. LPA conducted an unannounced required annual inspection visit.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station. LPA was asked to sign in. Temperature was taken by Caregiver. Infection Control signage was visible at entrance and throughout the facility.

At 9:45am 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.

Bedrooms: At 9:50am, LPA observed the Residents’ bedrooms. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are three Rooms(R). R#1, has one resident, R#2, has two residents and R#3, has 2 residents.

Bathrooms: At 10:00am, LPA observed the Residents’ restrooms. Restrooms were 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.

Kitchen: At 10:15am, LPA observed the kitchen/dining area. Knives are stored in a locked cabinet in the kitchen. 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. A meal Menu is displayed in the kitchen area. Emergency food supply is adequate for six residents and staff.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2021
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: ASHLEY'S GARDEN ELDERLY CARE
FACILITY NUMBER: 197609824
VISIT DATE: 07/02/2021
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Outdoor Space: At 10:20 am, LPA observed the Outdoor space. A shaded patio is available for residents to visit with family members. Side gate is unlocked. LPA observed an adequate supply of Personal Protection Equipment (PPE) in the garage, and bathroom cabinets. 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. Staff is tested weekly for COVID-19.

Facility Records: At 10:45 am, LPA reviewed staff and residents’ records. All flies are in good order, and meet


requirements.

No deficiencies were cited 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: 07/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021
LIC809 (FAS) - (06/04)
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