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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610255
Report Date: 05/08/2024
Date Signed: 05/08/2024 02:04:20 PM

Document Has Been Signed on 05/08/2024 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:AMAZING SENIOR CARE ON LASSEN, INC.FACILITY NUMBER:
197610255
ADMINISTRATOR/
DIRECTOR:		ALADADYAN, YELENAFACILITY TYPE:
740
ADDRESS:17127 LASSEN STTELEPHONE:
(818) 207-4220
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 6CENSUS: 6DATE:
05/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:55 AM
MET WITH:Yelena Aladadyan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:05 PM
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On 05/08/24, at 10:55 a.m., Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, annual visit. LPA was met by caregiver, Zhana Ghambaryan. The administrator Yelena Aladadyan arrived about 10 (ten) minutes later.

The physical plant was toured inside and out at 11:40 am.

Living/Dining Room Area: LPA observed the living room furniture to be clean and in good repair. The facility maintains a comfortable temperature at 69 degrees Fahrenheit. The fireplace is secured in the living room area covered by a black gate.

Bedrooms: All three (3) bedrooms are shared. The three (3) resident rooms are numbered. Two (2) of the bedrooms have a private bathroom. LPA observed rooms to have bedding sheets, pillowcase, blankets, nightstands, televisions, and sufficient lighting for each of the residents sharing the room.

Bathrooms: All three (3) bathrooms were toured and checked to make sure bathrooms were clean and in good repair. The hot water temperature measured within regulations of 112 degrees Fahrenheit and 114. The showers have non-slip bathmats and grab bars. There is another bathroom on your right hand side of the entrance of the facility.

Medications were kept in a locked cabinet in the bedroom hallway. All medications were properly labeled and inaccessible to residents. There is a complete first aid kit located in the kitchen.

LIC 809C-Continued

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE: DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2024
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: AMAZING SENIOR CARE ON LASSEN, INC.
FACILITY NUMBER: 197610255
VISIT DATE: 05/08/2024
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Kitchen Area: LPA inspected the kitchen area. The refrigerator was clean and in good operation. Fire extinguisher was observed to be full and dated November 2024. Knives and sharp objects were kept centrally stored and locked in a cabinet located in the kitchen on your left-hand side. LPA observed sufficient supply of seven (7) day non-perishable and perishable foods in the cabinet. The PPE is stocked in the kitchen area.

Garage: In addition, there is another refrigerator in the garage stored with extra food. The washer and dryer are also located in the garage. Cleaning supplies/toxins were kept locked in the garage being inaccessible to residents.

Outside: LPA toured the outside area. LPA observed a covered shaded area for residents and appropriate outdoor furniture. The facility has no body of water on the premises. There is one gate that is locked leading to the outside area towards the street. There are also ramps provided for wheelchair residents. There is a shed that contains extra wheelchairs and resident property. There is a side door on your left hand side of the entrance of the facility that leads to a bedroom for staff use only, separate from the property access. There are no residents in that area. LPA was able to tour that area.

Administration: The mitigation and the Infection control were reviewed and there was Covid 19 signs on the wall, hygiene sanitation signs, Personal Rights, Visitation Rights, Theft and Loss Policies, Emergency and Disaster Plan, Report of suspected abuse, Rights of Resident Council, Ombudsman and YES sign, surety bond was viewed, and it is up to date.

The staff and the resident files were in a secure/private location in the dining hall area on your left hand side.

The carbon monoxide is interconnected with the smoke detector was tested and it was operable.

An exit interview was conducted, no citations were issued, and a copy of this report was given to the administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024
LIC809 (FAS) - (06/04)
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