197610407-7-22-2024-31-AS-LDLC-D7F23W-20240722170302

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610407
Report Date: 07/22/2024
Date Signed: 07/22/2024 05:03:51 PM

Document Has Been Signed on 07/22/2024 05:03 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:	PURE ASSISTED LIVING		FACILITY NUMBER:	197610407
ADMINISTRATOR/ DIRECTOR:	GHAZARYAN, NARINE		FACILITY TYPE:	740
ADDRESS:	9550 REMICK AVE		TELEPHONE:	(818) 809-8559
CITY:	PACOIMA	STATE: CA	ZIP CODE:	91331
CAPACITY: 6		CENSUS: 6	DATE:	07/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:00 AM
MET WITH:	, Administrator, Armine Dishoyan		TIME VISIT/ INSPECTION COMPLETED:	04:45 PM

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Licensing Program Analyst (LPA) Leizl de la Cerra conducted an annual required visit and inspection of the facility. At 10:30AM Armine Dishoyan met LPA at the entrance and LPA explained the reason for the visit.

Resident and Staff Records reviews and interviews: At approximately 11:00AM to 3:00PM, six (6) out six (6) resident records were reviewed. Ten (10) staff records were reviewed to ensure compliance.
Interview of two (2) staff was conducted. Interview of two (2) clients was conducted. Medications for two (2) residents were reviewed and appear to be given as prescribed.

At 3:00PM LPA with the assistance of the administrator took a tour of the facility.
Outside: LPA toured the outside area. LPA observed a shaded sitting area for residents. There is a locked detached storage/laundry room which is located outside. This storage room is where the two (2) washer and a dryer is located along with laundry chemicals. This room is also used for storing supplies such as toiletries, PPE supplies, incontinence supplies and wheelchairs. Additionally, there are two sheds with locks used also for storage. The facility does not have any bodies of water.

Common Area: LPA observed the living room and furniture to be clean and in good repair. The fireplace located in the living room is covered and inaccessible to residents. The facility maintains a comfortable temperature at 78 degrees Fahrenheit. The air conditioner is operational. The facility smoke alarm system is hard wired and interconnected. The facility uses a dual Carbon Monoxide/Smoke alarm detectors all over the common areas of the facility. At 3:15PM they were tested and deemed operational. Facility maintains a telephone land line and it was observed to be operational. Required postings were observed in the hallway. The fire extinguisher is in the kitchen with purchase date of 11/14/2023. The facility is fire cleared for five (05) non-ambulatory residents; one (1) maybe bedridden in bedroom #4 and approve for six (6) hospice waiver.

Continued to LIC809-C

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Leizl De La Cerra
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024

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: PURE ASSISTED LIVING	FACILITY NUMBER: 197610407
	VISIT DATE: 07/22/2024

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Kitchen: The kitchen appliances were functional. The kitchen has a working gas stove, faucet, refrigerator, and microwave. LPA found enough food for at least three (3) days perishable and seven (7) days non-perishable which are properly stored. Knives were stored in a locked drawer in the kitchen. Food preparation areas are clean. Garbage can have a tight fitting cover. Kitchen cleaning supplies were stored in a locked cabinet. Residents' dining table accommodates six (6) people.
LPA observed a locked cabinet that contains all the residents' records, the staff records and the residents' medications. LPA observed the upper part of the cabinet and bottom part has locks and remained inaccessible to residents in care. Medications are centrally stored and locked in the cabinet. First-aid has all proper items and is current.

Bedrooms: There are four (4) bedrooms that were properly furnished with appropriate dresser, night stand, chair, beddings, and linens with sufficient lighting. Extra linens and beddings are stored in the hallway closet. Bedroom #1 is occupied by one (1) resident. Bedroom #2 is occupied by one (1) resident. Bedroom #4 is occupied by two (2) residents which has a private bathroom. Bedroom #3 is approved and cleared for one (1) bedridden patient is occupied by two(2) residents.

Bathrooms: There are two (2) bathrooms designated for residents use. The bathrooms were properly supplied and had functional fixtures. Grab bars and non-skid mats were observed. Hot water temperature was measured at 114.6 degrees.

Garage: There is no garage.

The facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed during today’s visit. Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Leizl De La Cerra
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024

LIC809 (FAS) - (06/04)

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