197610044-8-17-2021-29-AS-SWAR-C5YT9W-20210817143238

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610044
Report Date: 08/17/2021
Date Signed: 08/17/2021 02:46:42 PM

Document Has Been Signed on 08/17/2021 02:46 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:	MARY'S CHATEAU		FACILITY NUMBER:	197610044
ADMINISTRATOR:	PETIKYAN, MARY		FACILITY TYPE:	740
ADDRESS:	13912 VALERIO STREET		TELEPHONE:	(323) 333-8105
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY: 6		CENSUS: 5	DATE:	08/17/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Mary Petikyan, Administrator		TIME COMPLETED:	02:45 PM

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Licensing Program Analyst (LPA) Salia Walker arrived at the facility unannounced to conduct a required Annual visit at 12:45 p.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Mary Petikyan at 12:58 p.m., and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside at 12:59 p.m., to ensure there are no health and safety hazards.

BEDROOMS: The LPA observed the resident bedrooms which were furnished with clean linens, appropriate furnishings and sufficient lighting.

RESTROOMS: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA advised the Administrator to ensure that bathrooms were stocked with paper towels and hand-washing signs. Restroom one (1) hot water measured 114.9 Fahrenheit at 01:18 p.m. Restroom two (2) hot water measured 113.4 Fahrenheit at 01:22 p.m. Restroom three (3) hot water measured 107.3 Fahrenheit at 01:24 p.m.

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 properly stored and locked at time of visit. Hot water measured 112.7 Fahrenheit at 01:01 p.m.

Continue on LIC 809C..

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021

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: MARY'S CHATEAU	FACILITY NUMBER: 197610044
	VISIT DATE: 08/17/2021

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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 required postings in the hallway, with the exception of CDSS PINs. The LPA advised the administrator to post required CDSS PINs to be available for staff, and residents. The facility Laundry room is located in the hallway locked and secured. All chemicals, and detergent are inaccessible to residents in care. Medications are stored in locked file cabinets located in the dining room. One fire extinguisher was observed to be fully charged and purchased on 09/05/2020. The LPA advised the administrator to have fire extinguisher replaced.

BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. The garage is attached to the facility. The garage contains additional nonperishable, and perishable food items. The garage also contains emergency water supply for each resident, and staff.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. The LPA did not observe an adequate supply of Personal Protection Equipment (PPE). The LPA provided resources for facility 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 does not have a confirmed case of COVID-19 at this time, and the LPA reviewed facility’s policies and procedures as it pertains to infection control.

Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021

LIC809 (FAS) - (06/04)

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