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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610176
Report Date: 12/31/2024
Date Signed: 12/31/2024 02:48:41 PM

Document Has Been Signed on 12/31/2024 02:48 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:ESSENTIAL CARE ASSISTED LIVINGFACILITY NUMBER:
197610176
ADMINISTRATOR/
DIRECTOR:		KHACHATRYAN, VERZHINEFACILITY TYPE:
740
ADDRESS:3132 WAVERLY DR.TELEPHONE:
(818) 284-7607
CITY:LOS ANGELESSTATE: CAZIP CODE:
90027
CAPACITY: 6CENSUS: 1DATE:
12/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH: Verzhine KhachatryanTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On 12/31/24, 9:15 am, Licensing Program Analyst (LPA) Raymond Comer conducted an unannounced Annual visit to this facility. LPA met with Facility Administrator, Khachatryan Verzhine, and reason for the visit was discussed.

Facility is licensed as a single-story residence, approved for six (6) non-Ambulatory, with one (1) bedridden. Hospice waiver for six (6). Facility has four (4) resident bedrooms, and two (2) bathrooms.

At 9:25 am, LPA conducted a tour of the physical plant with the Administrator and observed the following:

Physical plant was inspected for cleanliness and condition. Facility’s main door is the primary entry/exit access. Alternative exits are located in all bedrooms. Visitor sign-in sheet, hand sanitizer, gloves and masks are available. Covid 19 prevention protocols are posted. Room temperature is comfortable; wall thermostat displays a setting of 75.0°F. within the required range. An approved Mitigation and Infection Control plan is on file. Hand washing, coughing etiquette, and other necessary signage are prominently displayed throughout the facility. Required postings observed to be current. Disaster drills were last conducted on 12/2024.

Fire Detection/Protection system is present in the facility. Dual Smoke and Carbon monoxide detectors function properly. LPA observed a fire extinguisher located on the wall near the kitchen. Extinguisher displays service date: 12/2024.

[LIC 809C]-Continued---

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE: DATE: 12/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/31/2024
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ESSENTIAL CARE ASSISTED LIVING
FACILITY NUMBER: 197610176
VISIT DATE: 12/31/2024
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Kitchen: At 10:05 am, LPA observed kitchen as clean, equipped with a functional stove, refrigerator, with adequate supply of perishables and non-perishable food. Open pantry space stores dry food, condiments, and can goods. Emergency food is stored in a kitchen cabinets. Food is observed as properly labeled and stored. Kitchen cabinets store dishes, plastic, paper goods and utensils. Knives/Sharps are stored in a locked top drawer inaccessible to residents. No pesticides, nor toxins observed.

Medications are stored in a secured and locked cabinet located in the living room. A stocked first aid kit and manual was observed in medication cabinet.



Laundry At 10:25 am, LPA observed laundry room located in outside patio area. Laundry space observed to be clean and clear from obstructions. Soaps and other cleaning agents are stored and inaccessible to residents. LPA observed a storage cabinet containing towels, clean linen and blankets appearing sufficient for residents.

Commons: LPA observed all common areas of the facility, including the living room and dining room. LPA observed common areas to be clean and organized. Living room is supplied with sitting area, television, stored games, and reading materials. Fireplace in the living room area is screened, preventing access. No fireplace tools present. Furniture and fixtures are clean and good condition. Facility telephone is observed as operational.



Bedrooms: Bedrooms are clean with sufficient lighting, properly furnished with sufficient closet space, bedding, linens, and adequate furnishings.

Bathrooms were observed to be clean and sanitary with necessary supplies and required safety fixtures (grab bars, anti-slip floor stripping). Hand towels and washcloths are not shared. Hot water temperature measured at 106.0°F. Within the required range.

Outdoor (backyard) area observed to have a shaded patio, with table with sufficient seating for the residents. Outdoor furniture observed to be in good condition. Backyard contains a swimming pool whose perimeter is fenced. Entry gate secured and locked, inaccessible to residents.

[LIC 809C]-Continued---

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 12/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: ESSENTIAL CARE ASSISTED LIVING
FACILITY NUMBER: 197610176
VISIT DATE: 12/31/2024
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Resident records: Records are stored in living room area cabinets, which are locked and inaccessible to residents. Records were reviewed for current IPP and/or Needs and Services plans, physician report, and admission agreements. Resident records appeared to be complete and current.

Staff records: Records are stored in living room area cabinets, which are locked and inaccessible to residents. Criminal record clearances were present, and Staff are associated to this facility. Staff records appear to be complete and current.

There were no immediate health and safety hazards observed at the time of this inspection. Exit interview conducted and a copy of this report was given to the Administrator.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 12/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2024
LIC809 (FAS) - (06/04)
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