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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609980
Report Date: 03/05/2024
Date Signed: 03/06/2024 09:01:02 AM

Document Has Been Signed on 03/06/2024 09:01 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
WOODLAND HILLS N.ASC, 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: 6DATE:
03/05/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:13 PM
MET WITH:Emma ElazyanTIME COMPLETED:
03:14 PM
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Licensing Program Analyst (LPA) Sandra Urena arrived unannounced to conduct an annual inspection- continuation visit. The LPA was greeted by staff. Staff contacted the Administrator by phone. The LPA communicated with the administrator via phone, and informed them of the visit.

RECORDS: At 12:16 p.m. the Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Records were in order.

MEDICATIONS: Medications review began at 2:10 p.m.; medications are centrally stored and locked in a cabinet in the kitchen area; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

INFECTION CONTROL: 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 a single isolation room if the facility has a confirmed case of COVID-19.

The LPA reviewed the following documents:


- LIC500 Personnel Report


Facility staff representative signed today's report. A copy of the report was issued.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2024
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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