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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609824
Report Date: 07/25/2022
Date Signed: 07/28/2022 11:30:04 AM

Document Has Been Signed on 07/28/2022 11:30 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: 6DATE:
07/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Asmik Arzuyan TIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Sandra Urena, arrived at the facility at 1:30 p.m., unannounced to conduct a required annual inspection. This annual inspection had a specific emphasis on infection control practices and procedures. LPA Urena met with staff Asmik Arzuyan , and explained the reason for the 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 1:45 p.m, the LPA and the staff 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 1:50 p.m., the LPA and the staff observed the residents’ bedrooms. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are three Rooms(R). R#1, has two residents, R#2, has two residents, and R#3, has 2 residents.

Bathrooms: At 2:15 p.m., the LPA and staff 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.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2022
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: 07/25/2022
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Kitchen: At 2:30 p.m., the 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. Emergency food supply is adequate for six residents and staff. Fire extinguisher was purchased on 4/2022.

Outdoor Space: At 2:45 p.m., the LPA and staff 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.

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: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2022
LIC809 (FAS) - (06/04)
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