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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610171
Report Date: 09/14/2022
Date Signed: 09/14/2022 03:30:54 PM

Document Has Been Signed on 09/14/2022 03:30 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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:HEART TO HEART SENIOR LIVINGFACILITY NUMBER:
197610171
ADMINISTRATOR:VERONIKA YEBEYANFACILITY TYPE:
740
ADDRESS:9330 ALDEA AVETELEPHONE:
(747) 202-0923
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 6CENSUS: 5DATE:
09/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Veronika Yebeyan TIME COMPLETED:
03:40 PM
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On 09/14/22 Licensing Program Analyst (LPA) Joscelyn Martinez arrived at the facility to conduct an unannounced annual inspection. Upon arrival LPA met with staff and later met Administrator Veronika Yebyean. The purpose of the visit was explained. Entrance interview conducted.

A physical plant tour was conducted at 2:30 p.m and the following was observed:

Infection Control: Covid-19 infection control signage were observed outside of the facility. Proper signage was also observed inside in the common areas. Staff screened LPA for covid symptoms and took LPA’s temperature. Facility has sufficient PPE supplies for more than 30 days. Food Inspection/Kitchen: LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers in the kitchen. Sharps are centrally stored in a locked area. Medication are centrally stored in a locked cabinet. Chemicals are locked and stored under the kitchen sink. Smoke detectors/carbon monoxide are located throughout the facility and are dual hardwired. Smoke detectors and carbon monoxide detectors were tested at approximately 3:10 p.m. and appear to be functional. Fire extinguishers were observed throughout the facility and are charged. Common Areas: All common areas were observed to be clean and properly furnished. Facility’s temperature at the time of the visit was 74 F. Laundry area is located in the hallway. Laundry chemicals are kept locked inside the cabinet. Resident Rooms: Facility has six (6) bedrooms designated for resident use. All six (6) bedrooms were toured and appear to be clean and properly furnished. LPA observed additional bedding and linens sufficient for all of the residents. All rooms have adequate lighting and furniture. Bathrooms: There are four (4) bathrooms in the facility of which three (3) are designated for resident’s use. LPA observed all bathrooms to be cleaned. The hot water was tested and measured 114.5 F, which is in regulation. Grab bars and non-skid were observed. (Continue on 809-C)

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2022
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HEART TO HEART SENIOR LIVING
FACILITY NUMBER: 197610171
VISIT DATE: 09/14/2022
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Outside: LPA toured the outside area and observed appropriate outdoor furniture with a shaded covered area for residents. There is a body of water that is gated and locked making it inaccessible to residents in care.

No deficiencies cited. Exit interview conducted. Report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC809 (FAS) - (06/04)
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