197610426-9-28-2023-31-AS-MCAA-CW4QKL-20230928121431

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610426
Report Date: 09/28/2023
Date Signed: 09/28/2023 12:14:39 PM

Document Has Been Signed on 09/28/2023 12:14 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:	MK QUALITY CARE ASSISTED LIVING		FACILITY NUMBER:	197610426
ADMINISTRATOR:	PLOKHOVA, IREN		FACILITY TYPE:	740
ADDRESS:	18960 KESWICK STREET		TELEPHONE:	(818) 648-0011
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY: 6		CENSUS: 4	DATE:	09/28/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Karapet Satelyan, Maryam Harutyunyan, Irene Plokhova		TIME COMPLETED:	12:30 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 Analysts (LPAs) Michael Cava, Huma Rahimi, and Leslie Ngo-Castaneda, conducted a Pre-Licensing Inspection with the applicant representative and administrator, Karapet Satelyan, Maryam Harutyunyan, and Irene Plokhova. An Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on March 24, 2023. A fire clearance was approved on August 30, 2023 for five (5) non-ambulatory residents and one (1) bedridden resident, for a total capacity of six. The applicant is also requesting a hospice waiver to retain four (4) residents. The smoke alarms and carbon monoxide detector are battery operated. The facility has one new fire extinguishers that was purchased on July 7, 2023. One fire extinguisher is located in dining room/kitchen area. A tour of the physical plant was initiated at approximately 9:30am and the following was observed: KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven and sink. There were adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). Knives were observed locked in a lock box. BEDROOMS: There are six (6) bedrooms designated for client use. All six (6) bedrooms are private. Per STD 850, bedroom number one is cleared for bedridden. All other rooms, are cleared for non-ambulatory. The applicant furnished the resident bedrooms with beds, night stand, chairs, dresser, bedding and linen. The bedrooms have sufficient lighting and closet space. BATHROOMS: The facility has four (4) bathrooms. Room three and four have a shared/common bathroom. The bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured between 107.01 to 108 degrees.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

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: MK QUALITY CARE ASSISTED LIVING	FACILITY NUMBER: 197610426
	VISIT DATE: 09/28/2023

NARRATIVE

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COMMON AREAS: These included the TV and activity room which were equipped with living room furniture, a television, tables and chairs. There is a fireplace with a screen and a glass slide. It is non-operational. No fireplace tools or fixtures present. The dining area has a large dining room table to accommodate six (6). There were no visible immediate hazards.

LAUNDRY ROOM: The laundry room is located in the in the hall beside room # 6. It was observed with two locked doors to make it inaccessible to the residents.

MEDICATIONS: The medication will be stored in a locked cabinet locked in the living room.

OFFICE/STAFF WORKSTATION: Staff workstation is located at the end of the hallway by resident room # 5.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. All entry and exit doors have a functional auditory alert when the doors open. The front yard of the facility has a patio and outdoor furniture to accommodate the six (6) residents. The facility front yard has sufficient yard space. There is a closed jacuzzi that is fenced all around with a gate that will be kept locked at all times. The fence surrounding the jacuzzi is approximately 5 feet high all around its parameters. You will need a key to unlock the padlock to gain entry to the jacuzzi as it is kept locked at all times.

In addition to the Pre-Licensing inspection, a Component III power point presentation was also held.

Pursuant to Title 22, Division 6 of the CA Code of Regulations, the facility's physical environment appears to be compliant and ready for licensure. CAB will be advised and a copy of this report provided.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC809 (FAS) - (06/04)

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