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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609851
Report Date: 10/04/2021
Date Signed: 10/04/2021 11:26:53 AM

Document Has Been Signed on 10/04/2021 11:26 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:VH CAREFACILITY NUMBER:
197609851
ADMINISTRATOR:VAHAGN HARUTYUNYANFACILITY TYPE:
740
ADDRESS:13945 SYLVAN STREETTELEPHONE:
(818) 322-8838
CITY:VAN NUYSSTATE: CAZIP CODE:
91401
CAPACITY: 6CENSUS: 5DATE:
10/04/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Vahagn Harutyunyan TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Brian Balisi arrived to this facility today to conduct a One (1) year Required inspection of this facility with emphasis on infection control practices and procedures. LPA met with Vahagn Harutyunyan and explained the reason for the visit.

LPA inspected facility for fire safety, personal accommodations and services, and food service. All hardwired smoke alarms and combined carbon monoxide detectors were tested and function properly at this time. LPA observed two fire extinguishers to be fully charged.

LPA conducted physical plant tour of the facility with Vahagn.All residents' bedrooms were inspected.  Common areas, including living room and dining room appeared clean and were properly furnished.

The kitchen appeared clean and the appliances and fixtures functional.  Refrigerated and frozen foods were stored at proper temperature. There was a sufficient amount of perishable and non-perishable food at the facility and properly stored. Sharp objects in the locked top cabinet to the right of the kitchen sink. Between 9am - 12pm, LPA observed staff preparing snacks . There were no pesticides or poisons observed near any food areas. 

Entry/exits were free of obstruction.  The outdoor area was clean and free of hazards.  The medications were locked in the corner cabinet of kitchen.

(continued from LIC 809)
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2021
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: VH CARE
FACILITY NUMBER: 197609851
VISIT DATE: 10/04/2021
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Continued from 809

Personal accommodations in resident bedrooms and bathrooms were observed for safety, privacy, and comfort.  Random resident rooms were inspected and observed with all required furnishings and grab bars and nonskid surfaces in the bathrooms.  Hot water temperature in resident bathrooms were checked and measured within the required range at 112 degrees Fahrenheit.

The LPA spoke with Vahagn regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has 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 the master bedroom with single isolation rooms if the facility has a confirmed case of COVID-19. COVID-19 testing is conducted weekly if anyone shows any symptoms. The facility’s policies and procedures as it pertains to infection control are adequate at this time.

LPA will provide Vahagn with information and resources to have all staff fit tested for N95 respirators.


No deficiencies cited. Exit interview conducted. A copy of the report was issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021
LIC809 (FAS) - (06/04)
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