197610163-8-30-2021-31-AS-YAVN-C6DUHV-20210830153630

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610163
Report Date: 08/30/2021
Date Signed: 08/30/2021 03:40:01 PM

Document Has Been Signed on 08/30/2021 03:40 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	A & V SENIOR CARE		FACILITY NUMBER:	197610163
ADMINISTRATOR:	GONZALEZ, LORENA		FACILITY TYPE:	740
ADDRESS:	14928 HIAWATHA STREET		TELEPHONE:	(818) 921-0589
CITY:	MISSION HILLS	STATE: CA	ZIP CODE:	91345
CAPACITY: 6		CENSUS: 5	DATE:	08/30/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Lorena Gonzales		TIME COMPLETED:	03:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	An unannounced Pre-Licensing inspection visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. When arriving to the property LPA contacted administrator to complete the pre-inspection COVID 19 questions. Upon entrance to the facility LPA met with staff Edgar Prepuse and Marissa Agngarayngay. Temperature check and screening for LPA was completed by staff. BEDROOMS: The physical plant was toured inside and out. A fire clearance was approved on 7/26/2021 for the following. Room # 2 is cleared for 2 ambulatory, Room # 3 is cleared for 1 non-ambulatory, Room # 4 is cleared for 1 non-ambulatory and Room # 5 is cleared for 2 non-ambulatory one of which may be bedridden. This facility has four resident bedrooms. One out of four rooms (Room #5) has a direct exit to the exterior. Rooms were set up with beds, night stands, lamps, chests of drawers, chairs and closet space. Lighting in the rooms was adequate. Room # 1 is the designated staff room. BATHROOMS: There are 2 full bathrooms. One out of four rooms (Room #5) has an en-suite bathroom. Bathrooms are clean and sanitary and in operating condition with appropriately stalled grab bars and non-skid mats in the showers. KITCHEN: Kitchen knives and sharp objects will be kept locked and inaccessible in locked drawers, Kitchen appliances were in operable condition. The facility had a sufficient supply of non-perishable food. The supply of dishes was adequate. The fire extinguisher is in the kitchen and was inspected in 5/2021. There is adequate seating for dining in the dinning are. Medications will be stored in a locked cabinet in the kitchen. There was a washer and dryer area in the kitchen near the staff room.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021

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 7

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: A & V SENIOR CARE	FACILITY NUMBER: 197610163
	VISIT DATE: 08/30/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

COMMON AREAS: The common areas were appropriately furnished, and lighting was adequate. The LPA observed a fireplace in the living room which was screened and inaccessible. The smoke alarm system is hard wired. Smoke and carbon monoxide detectors were tested and were operational at the time of the visit. The facility had a complete first aid kit. Required postings were not observed throughout the facility. A discussion was held with the applicant who stated she will ensure to post all information as required upon licensure.

OUTSIDE AREAS: The exterior passageways were clean and clear of any obstructions. The backyard has a covered outdoor area equipped with furniture for resident use. There are no bodies of water noted at this time.

Component III was conducted with applicant in conjunction with this visit.

While conducting review of the residents records it was observed that resident 1 R1 is who is non-ambulatory and utilizes a wheelchair is residing in room #2 which is currently fire cleared for 2 ambulatory. Administrator will speak with the residents and/or their responsible parties to determine what room changes will be made. Once completed Administrator will notify the LPA In writing.

Administrator will also submit an updated facility sketch which complies with the fire clearance that was granted in July.

The administrator was informed that she will need complete all corrections identified in this report and discussed during the visit in order to complete the change of ownership process. Once the corrections are made LPA will notify the Centralized Application Bureau (CAB). The CAB Analyst will notify the applicant when the license has been approved.

Exit interview conducted with applicant, and copy of report emailed to the applicant.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021

LIC809 (FAS) - (06/04)

Page: 7 of 7