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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610043
Report Date: 04/01/2022
Date Signed: 04/01/2022 04:30:39 PM

Document Has Been Signed on 04/01/2022 04:30 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:MEGAN'S PLACEFACILITY NUMBER:
197610043
ADMINISTRATOR:OSBORN, ANNIEFACILITY TYPE:
740
ADDRESS:7708 ETHEL AVENUETELEPHONE:
(818) 853-7654
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 4DATE:
04/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Annie OsbornTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual visit at 11:15 a.m. This annual had a specific emphasis on infection control practices and procedures. The LPA initially met with facility staff Vergouhy Nazarian, and discussed the reason for the visit. Administrator Annie Osborn arrived at 11:50 a.m.

The LPA, along with facility staff Vergouhy Nazarian, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

BEDROOMS: The LPA observed that the residents' bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 4 (four) total bedrooms; 3 (three) are for resident use and 1 (one) is designated as a staff room.

RESTROOMS: Residents’ restroom is clean and sanitary condition. Shower is equiped with grab bars and non-skid surfaces. Paper towels were available for drying hands. Hand washing signs were displayed, and sufficient amounts of soap and paper product in the restroom restroom.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/01/2022
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 2
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: MEGAN'S PLACE
FACILITY NUMBER: 197610043
VISIT DATE: 04/01/2022
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OUTDOOR: The backyard has a covered outdoor area equipped with furniture for residents use. There were no bodies of water noted. The garage was observed locked and contained the laundry area, as well as emergency food supply, and storage.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable, and non-perishable food. All knives and cleaning supplies were observed to be locked, and properly stored at the time of the visit.

INFECTION CONTROL: LPA Urena observed an adequate supply of Personal Protective 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 facility has not had a confirmed resident case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies cited during this visit. Exit interview was conducted. The report was reviewed with Director Annie Osborn, 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: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022
LIC809 (FAS) - (06/04)
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