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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610102
Report Date: 12/09/2024
Date Signed: 12/09/2024 02:04:36 PM

Document Has Been Signed on 12/09/2024 02:04 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ALLEVIATE CAREFACILITY NUMBER:
197610102
ADMINISTRATOR/
DIRECTOR:		EDGAR GHAZARYANFACILITY TYPE:
740
ADDRESS:20930 GAULT STREETTELEPHONE:
(818) 378-2772
CITY:CANOGA PARKSTATE: CAZIP CODE:
91303
CAPACITY: 6CENSUS: 6DATE:
12/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Edgar Ghazaryan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
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At 11:40 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced annual visit. LPA met with staff and later Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out.

The facility is a single story building with 5 bedrooms, 3 bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for 6 residents, of which 5 may be non-ambulatory. The facility serves residents with dementia. Approved hospice waivers for 5.

Kitchen: At approximately, 11:50 AM LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. Kitchen surfaces were sanitary, and all appliances were functional. Sharps were locked below the counter, and cleaning solutions were locked in separate cabinet in the kitchen. LPA observed a fully charged fire extinguisher in the kitchen. It was last inspected on 10/02/2024.

Medications: At approximately, 11:55 AM LPA observed medications are centrally stored and locked in the front entrance/office of the facility in a cabinet. LPA also observed an additional locked cabinet where resident and staff files are kept.

Bedrooms: LPA observed total of five (5) bedrooms designated for resident use. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Facility has awake staff.

Bathrooms: LPA observed three (3) bathrooms and all bathrooms appeared to be clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bar and resident's bathroom had non-skid mat. LPA observed appropriate hand washing signs posted in each bathroom. At 12:13 PM, hot water temperature measured at 116.2°F.

Continue on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2024
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ALLEVIATE CARE
FACILITY NUMBER: 197610102
VISIT DATE: 12/09/2024
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Common Areas: The facility maintains a comfortable temperature at 73°F. The living room and dining area appeared clean and were properly furnished. The living room has a television, comfortable furniture. No obstructions and or tripping hazards throughout the facility. LPA observed an operable washer and dryer in locked room next to the garage. All detergents were stored and locked. The garage was also observed locked, which had extra emergency food and cleaning supplies stored inside.

Smoke detectors/carbon monoxide. At 12:20 PM, LPA tested the dual-function smoke and carbon monoxide detector to be operational. When tested, 3 out of 3 detectors functioned simultaneously, and the fire door closed. 2 out of 2 auditory alarms were on and functioning.

Outside areas: At approximately, 12:25 PM LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There is no bodies of water or swimming pool at the facility. All emergency exit paths were free from obstructions. Exit gates were unlocked.

Between 12:30 PM to 1:30 PM, LPA reviewed records of five (5) residents and two (2) staff. Resident and staff records appeared to be complete and updated.

Administrative: LPA collected Certificate of Liability Insurance, and LIC500.

No deficiency cited during today’s visit.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
LIC809 (FAS) - (06/04)
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