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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609934
Report Date: 05/01/2023
Date Signed: 05/01/2023 04:54:00 PM

Document Has Been Signed on 05/01/2023 04:54 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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:KAREN'S HOME FOR SENIORS, INC.FACILITY NUMBER:
197609934
ADMINISTRATOR:ZINKOFSKY, CLARITAFACILITY TYPE:
740
ADDRESS:16822 ADDISON STREETTELEPHONE:
(818) 886-8360
CITY:ENCINOSTATE: CAZIP CODE:
91436
CAPACITY: 6CENSUS: 6DATE:
05/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Grace JabaldeTIME COMPLETED:
05:00 PM
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At 1:10 pm, Licensing Program Analyst (LPA), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility. LPA was greeted by staff and disclosed the purpose of the visit. The administrator was contacted. LPA Smith spoke with administrator over phone and he revealed he is out of town and not able to come to the facility. The administrator authorized staff Grace Jabalde to sign report.

LPA conducted a tour of the physical plant at approximately 1:17 pm to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Common areas were observed for the ability to safely serve the needs residents. These included the kitchen/dining room combination, living room and family room. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to be furnished appropriately with adequate seating for residents.

LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The
kitchen food supply was observed and sufficient for the six (6) residents currently residing there. Two (2) days of
perishable food observed. The freezer is stocked with meats and frozen vegetables. Sharps are stored in locked kitchen drawer. The resident medications and first aid kit stored in locked cabinet next to refrigerator and observed to be locked and inaccessible to residents. There is one (1) fire extinguisher attached to kitchen wall and observed to be charged.

Laundry room is located in walk through next to kitchen The appliances observed to be functional. Toxins stored in locked floor cabinet next to dryer and was observed to be locked and inaccessible to residents.
The facility has a total of six (6) bedrooms and two (2) bathrooms: there is one (1) shared and four (4) private bedrooms for residents and one (1) bedroom for staff.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: KAREN'S HOME FOR SENIORS, INC.
FACILITY NUMBER: 197609934
VISIT DATE: 05/01/2023
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(Cont from 809)

The resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for
each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases,
mattress pads, and blankets. LPA observed a supply of linens in hall closet.

Each bathroom had the following items available: hand soap, paper towels, and trash cans. The hot water temperature was measured for in bathrooms to ensure it within the required range for residents’ comfort and safety. The water temperature range was measured at 123.7- and 118.7-degrees Fahrenheit for main bathroom shower. Main bathroom hot water faucet stuck in off position.

Backyard has the following: (1) one patio table, umbrella with seating. Patio furniture observed to be in good repair.

Detached Garage: Used for storage of equipment and furniture. There is no body of water in the facility.

Storage shed used for storage in backyard observed to be locked and inaccessible to residents.

Smoke detectors/carbon monoxide detector were tested and operable at time of visit.

Facility grounds were free of hazards. There were no immediate health and safety hazard observed during the day of inspection.

At approximately 02:34 pm, LPA reviewed files for the six (6) residents. Resident files included medical assessments, Appraisal/Needs and services plans, admissions agreements. Staff documents reviewed for two (2) staff. Staff files had the appropriate training's.

Technical Violation for main bathroom hot water faucet. No deficiencies cited.

Exit Interview Conducted / A Copy of the Report Issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023
LIC809 (FAS) - (06/04)
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