197610368-1-19-2023-31-AS-JGTN-CN8VMA-20230119153314

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610368
Report Date: 01/19/2023
Date Signed: 01/19/2023 03:33:19 PM

Document Has Been Signed on 01/19/2023 03:33 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:	ADVANCED SENIOR LIVING LLC		FACILITY NUMBER:	197610368
ADMINISTRATOR:	SANTOS, CATHERINE		FACILITY TYPE:	740
ADDRESS:	7017 DEVERON RIDGE ROAD		TELEPHONE:	(818) 300-4987
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY: 6		CENSUS: 4	DATE:	01/19/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:06 AM
MET WITH:	Catherine Santos - Administrator		TIME COMPLETED:	01:00 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	Licensing Program Analyst (LPA) Gary Tan conducted an announced Pre Licensing visit to this facility and met with applicant representative Juvy Silva and administrator Catherine Santos. The applicant is "Advanced Senior Living LLC". Fire Clearance dated 12/08/2022 was received for five (5) non-ambulatory residents, one of which may be bedridden on room #5. Purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with the rules and regulations of California Code of Regulations, Title 22, Division 6. Facility is a single storey home. Today's site visit consisted of LPA touring the physical plant inside and outside at 10:30 AM and observed the following: The facility smoke alarm are hard wired and interconnected. There are carbon monoxide detectors installed at the facility. The fire extinguisher is located in the kitchen and was observed to be fully charged and last inspected on 11/19/22. Hot water was tested in the common bathroom and measured at a range of 113.6°F to 114.9°F. There is a functioning telephone on the premises. An emergency exit plan/sketch is posted on the hallway wall with other posting requirements. There are five (5) resident bedrooms, only one (1) room is a shared room. Resident bedrooms were observed to be appropriately furnished. The common areas (living room, kitchen and dining areas) were appropriately furnished and lighting was adequate. The living room has a television and comfortable furniture. Resident and staff records are stored in a locked filing cabinet in the laundry room located adjacent to the living room near an exit. Medications are stored in a designated secured cabinet near the dining area. The first aid kit is readily available. There are three (3) bathrooms in the facility, all bathrooms have non-skid mats and appropriate grab bars installed. (continued on LIC 809-C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ADVANCED SENIOR LIVING LLC	FACILITY NUMBER: 197610368
	VISIT DATE: 01/19/2023

NARRATIVE

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(continued from LIC 809)

The kitchen knives and sharps are stored in a locked drawer in the kitchen. Kitchen cleaning supplies are stored in a locked cabinet in below the sink. Laundry detergents, cleaning supplies and other toxins are stored in a locked cabinet in the garage The garage has no access from inside the house and was observed to be locked and inaccessible to residents. The garage is also being used as stock room for tools, PPE and other old equipment. The necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on all doors and locked areas for centrally stored medications. Facility appears to be clean and in good repair. Appliances in the kitchen appeared to be functional.

There is a sitting area in the backyard for residents to conduct outdoor activities. The Sun Room is enclosed for the safety of the residents. The backyard is fenced. There is no body of water in the facility.

The administrator has been an certified for more than three (3) years and current administrator to their other facility Advanced Home Care Senior Living II (197610188) so Component III is waived as approved by LPM Nargaryan.

Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.

Exit interview conducted and copy of this report issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

LIC809 (FAS) - (06/04)

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