<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610426
Report Date: 10/10/2024
Date Signed: 10/10/2024 02:52:19 PM

Document Has Been Signed on 10/10/2024 02:52 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:MK QUALITY CARE ASSISTED LIVINGFACILITY NUMBER:
197610426
ADMINISTRATOR/
DIRECTOR:		PLOKHOVA, IRENFACILITY TYPE:
740
ADDRESS:18960 KESWICK STREETTELEPHONE:
(818) 648-0011
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 6CENSUS: 4DATE:
10/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:05 PM
MET WITH:Maryam Harutyunyan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:25 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
At 12:05 PM, Licensing Program Analyst (LPA) Huma Rahimi, conducted an unannounced annual inspection at the facility mentioned above. LPA met with the Administrator Maryam Harutyunyan and explained the reason for the visit. Physical tour was conducted with the Administrator and LPA observed the following:

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.



MEDICATIONS: LPA observed the medication locked and inaccessible to residents in care in a cabinet in the living room; There was a complete first aid kit available in the medication cabinet.

SAFETY: The smoke alarms and carbon monoxide detector are battery operated. The facility has one new fire extinguishers that was purchased on 12/05/2023. One fire extinguisher is located in dining room/kitchen area.

BEDROOMS: There are six (6) bedrooms designated for client use. All six (6) bedrooms are private. Bedroom number one is cleared for bedridden. All other rooms are cleared for non-ambulatory. All bedrooms are furnished with beds, night stand, chairs, dresser, bedding and linen. The bedrooms have sufficient lighting and closet space.

Continue on LIC 809C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: MK QUALITY CARE ASSISTED LIVING
FACILITY NUMBER: 197610426
VISIT DATE: 10/10/2024
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
26
27
28
29
30
31
32
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 117.05 degrees.

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.

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.

Between 1:45 PM to 3:00 PM, LPA reviewed records of four (4) residents and two (2) staff. Residents and staff records appeared to be complete and updated

Administrative: LPA collected Certificate of Liability Insurance, and LIC500.

No deficiency cited during today’s visit.

Exit interview conducted and copy of this report signed and delivered.




SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2