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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609980
Report Date: 02/03/2023
Date Signed: 02/03/2023 02:02:15 PM

Document Has Been Signed on 02/03/2023 02:02 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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:AMY'S PARADISE HOME OF ANGELS INC.FACILITY NUMBER:
197609980
ADMINISTRATOR:EMMA AVETISYANFACILITY TYPE:
740
ADDRESS:11950 ROSCOE BLVDTELEPHONE:
(310) 913-6161
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 5DATE:
02/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:12 AM
MET WITH:Emma Elazyan TIME COMPLETED:
02:00 PM
NARRATIVE
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On 02/03/2023, Licensing Program Analyst (LPA) Sandra Urena, arrived at the facility at 10:12 a.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 , and explained the reason for the visit. Staff called administrator Emma Avetisyan on the phone, and the LPA explained the reason for the visit. Ms. Avetisyan instructed staff Emma Elazyan to give the LPA tour of the facility, and to sign the inspection report.

Infection Control: Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed 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 a single isolation room if the facility has a confirmed case of COVID-19.

At 10:25 a.m., LPA Urena and staff conducted a tour of the inside and outside the facility to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Common Areas: The walls and flooring were observed to be clean and in good condition. At the time of the visit, common seating area, and dining room furniture was observed to be clean and in good condition. During the tour, it was observed that the signal system for the front door was broken. a

Continues on LIC809C ...

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2023
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: AMY'S PARADISE HOME OF ANGELS INC.
FACILITY NUMBER: 197609980
VISIT DATE: 02/03/2023
NARRATIVE
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Kitchen: Knives are stored in a locked cabinet drawer. 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. Emergency food supply is adequate for six residents and two staff. The laundry room is equipped with a functioning washer and dryer. The room was locked at the time of inspection. During of the pantry inspection, at 10:36 a.m. the LPA observed found several cans of food to have expired on 2021 and 2022. Fire extinguisher is found in the kitchen area, at 11:15 a.m. the LPA observed that the fire extinguisher had expired as 02/26/2021.

Bedrooms: Bedrooms were furnished appropriately with appropriate furnishings and sufficient lighting. Linens are clean and in good condition. Extra linens are found stored in the linen closet located between bedrooms #1 and #2.

Bathrooms: Restroom was clean, shower area was in clean condition with grab bars, and a non-skid mat available. Paper towels were available for drying hands. Hand washing sign was displayed, and sufficient amounts of soap and paper products in the bathroom.

Outdoor Space: Backyard has a covered outdoor area equipped with outdoor furniture for residents’ use. There were no bodies of water noted. Side gate is unlocked, however at 11:47 a.m. the LPA observed that the gate had a piece of wood placed against the wood gate to prevent a resident from exiting the premises. The gate has an alarm system, however the system is broken. Toxic materials(Charcoal Fluid) was found outside on the barbecue grill( bottom part) within reach to residents.



Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Deficiencies were cited during this visit. Exit interview was conducted. The report was reviewed with licensee representative, signatures were obtained, and a copy of the report was provided.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
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Document Has Been Signed on 02/03/2023 02:02 PM - It Cannot Be Edited


Created By: Sandra Urena On 02/03/2023 at 12:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMY'S PARADISE HOME OF ANGELS INC.
FACILITY NUMBER: 197609980

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
The following should be strored inaccesible to residents with dementia... toxic substances.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in as two out of two bottles of charcoal fluid were observed by the barbecue grill outdoors, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2023
Plan of Correction
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Licensee agrees to provide training to staff about locking and making all toxic substances inaccessible to residents. Send proof of training to CCLD by 02/06/2023.
Type A
Section Cited
CCR
87705(j)

Licensee shall have an auditory device to monitor exits, if it presents a hazard to any residents.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above as two out of two signal devices were not installed correctly for front door and outdoor gate, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2023
Plan of Correction
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Licensee agrees to install correctly the auditory devices and send pictures ti CCLD by 02/06/2023.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Sandra Urena
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/03/2023 02:02 PM - It Cannot Be Edited


Created By: Sandra Urena On 02/03/2023 at 01:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMY'S PARADISE HOME OF ANGELS INC.
FACILITY NUMBER: 197609980

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80020(a)
All facilities shall secure and maintain a fire clearance approved by the city or county fire department...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above as one out of one fire extinguishers were found to have been serviced on 02/26/2021, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2023
Plan of Correction
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Licensee agrees to purchase a new fire extinguisher , and send to CCLD pictures of the receipt for the new fire extinguisher by 02/06/2023.
Type B
Section Cited
CCR
1569.695(a)(2)
Plans for the facilityto be self-reliant for a period of not less than 72 hoursduring an emergency...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as canned food was found to have expired on 2021 and 2022, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2023
Plan of Correction
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Licensee agrees to purchase additional canned food for emergency supplies, and send a picture of the receipt and pictures to CCLD of can goods for the emergency supply.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Sandra Urena
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2023


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