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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610044
Report Date: 08/06/2022
Date Signed: 08/06/2022 03:37:49 PM

Document Has Been Signed on 08/06/2022 03:37 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 CHATEAUFACILITY NUMBER:
197610044
ADMINISTRATOR:PETIKYAN, MARYFACILITY TYPE:
740
ADDRESS:13912 VALERIO STREETTELEPHONE:
(323) 333-8105
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY: 6CENSUS: 6DATE:
08/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Melada MarsubyanTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a required annual visit. This annual had a specific emphasis on infection control practices. The LPA initially met with staff, whom contacted the Administrator. The LPA spoke with Administrator Mary Petikyan over the phone and informed them of the reason for the visit. The LPA toured the facility to ensure there are no health and safety hazards.
The LPA spoke with residents during the tour; residents appeared satisfied and voiced no concerns.

KITCHEN: Knives and chemicals are locked inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: Bedrooms had appropriate furniture, clean linens and sufficient lighting. Rooms were clean and clear of obstructions. RESTROOMS: The three restrooms were clean and sanitary with grab bars and non-skid surfaces. At 2:40 p.m., water temperature measured at 106.8 F. Restrooms were stocked with soap and paper towels. COMMON SPACES: The facility maintained a temperature of 74 degrees. There is a locked hallway closet with linens and supplies. Smoke detectors and carbon monoxide detectors were operable. Living room and dining furniture were observed in good condition. Medications, staff and resident files are locked inaccessible. Fire extinguisher was purchased 8/18/2021. The backyard and exterior area of the facility had furniture and a covered area for resident use. No obstructions observed in the exterior or interior. No bodies of water noted.

INFECTION CONTROL: There is a central entry point for screening and temperature checks. Staff were wearing face coverings. Signs were posted that promoted good hand hygiene, physical distancing, and cough/sneeze etiquette. The Administrator requested additional PPE. The facility’s cleaning protocol is sufficient. There is record of staff and resident vaccinations. The facility can designate a room to isolate persons if there is a confirmed case of COVID-19. Staff are up to date regarding guidelines around visitation and vaccine requirements. The policies and procedures pertaining to infection control were adequate.

No deficiencies cited. Exit interview conducted. Staff were authorized to sign the report. Report issued.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2022
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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