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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609950
Report Date: 02/03/2022
Date Signed: 02/03/2022 02:57:52 PM

Document Has Been Signed on 02/03/2022 02:57 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:PRIME RESIDENTIAL SENIOR CAREFACILITY NUMBER:
197609950
ADMINISTRATOR:KHECHIKYAN, SOFYAFACILITY TYPE:
740
ADDRESS:19418 LANARK STREETTELEPHONE:
(818) 626-8553
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 6CENSUS: 5DATE:
02/03/2022
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Sofya KhechikyanTIME COMPLETED:
02:59 PM
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At approximately 12:35 PM on 02/03/22, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection using the Infection Control Domain of the Compliance and Regulatory Enforcement (CARE) Tools. LPA met with staff and later Administrator and disclosed the reason for the visit.

Entry: LPA observed a sign posted on the front door regarding the facility’s visitation policy and COVID precautions. The walkway and front yard were well maintained.

Screening: Staff took LPA’s temperature and requested LPA sign in on the visitor log. LPA recorded name and time of arrival. LPA recommended two additional columns for visitor temperature and symptom check. LPA also observed gowns, N95 masks, surgical masks, surgical masks, gloves, and sanitizer. Beside the visitor log was a binder for daily documentation of resident temperatures.

At approximately 12:55 PM, LPA conducted a physical plant tour.

Bedrooms: The facility has 6 bedrooms in total. 1 bedroom is shared, and 5 bedrooms are private. All bedrooms were clean and odorless. Furniture was in good repair. Bedroom #1 was the shared bedroom. It contained a secured partition which provided social distance between beds. Bedroom #3 was designated for a bedridden resident, and the emergency exit was free from obstruction. Bedroom #4 also contained a secured partition but contained only one resident. Two other bedrooms were designated for staff and an individual who was fingerprinted and criminal background cleared.

LPA observed a locked closet in a hallway amongst Bedrooms #1, #2, and #3. The locked closet contained medication and extra hygiene supplies.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2022
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PRIME RESIDENTIAL SENIOR CARE
FACILITY NUMBER: 197609950
VISIT DATE: 02/03/2022
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Bathrooms: The facility had 3 bathrooms. Bathrooms #1 and #2 were located at the front. They contained paper towels, liquid soap, and trash cans with tight fitting lids. Bathroom #3 was connected to Bedroom #4. It contained liquid soap, paper towels, a lidless trash can, and a shower with grab bars and a non-skid mat. LPA recommended a tight fitting lid for the trash can and a handwashing instruction sign

Common Areas: LPA observed a clean living room with furniture in good condition. Couches and seating was arranged to allow for social distancing. Television and board games were provided for entertainment. LPA observed a sink near Bedroom #4 where LPA recommended a handwashing instruction sign.

Garage: LPA entered a locked garage and saw cleaning supplies, hazardous liquids, detergents, extra PPE, and a refrigerator for extra food.

Outside and Back Yard: LPA toured the two side paths and back yard. Both emergency exit gates were unlocked, and paths were free from debris. The back yard contained a gardening space. LPA observed a resident under a shaded patio area.

LPA heard functioning auditory alarms on all exit doors.

The facility uses a call system which LPA heard several times.

Mitigation: At approximately 1:30 PM, Administrator and LPA discussed the facility’s mitigation plan. In the event of a COVID positive resident, the facility can provide the Staff Bedroom for isolation purposes.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
LIC809 (FAS) - (06/04)
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