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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610552
Report Date: 07/17/2024
Date Signed: 07/22/2024 01:21:13 PM

Document Has Been Signed on 07/22/2024 01:21 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:INGOMAR SENIOR CAREFACILITY NUMBER:
197610552
ADMINISTRATOR/
DIRECTOR:		BAREGHAMYAN, ELENFACILITY TYPE:
740
ADDRESS:19002 INGOMAR STREETTELEPHONE:
(818) 403-1803
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 6CENSUS: 0DATE:
07/17/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Elen Bareghamyan - AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 7/17/2024 at 9:30AM Licensing Program Analyst (LPA), Perchui Milena Khurshudyan conducted an announced Pre-Licensing visit to the above facility and met with facility Licensee Yegeyan Nazar and Administrator Elen Bareghamyan.

Fire Clearance was approved on 04/02/2024 for a maximum capacity of six (6) Non-ambulatory residents, of which one (1) can be Bedridden resident. Facility has Dementia Care Program. The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. The facility is a single-story building. Today's site visit consisted of LPA touring the physical plant inside and outside and observed the following:


KITCHEN: The facility has a Kitchen area that is equipped with a new refrigerator, microwave oven and sink. At 9:45AM, LPA observed adequate supplies of nonperishable food properly stored in the cabinets and inside the supply room. Perishable food items are not required at this time as there are no residents in the facility. Licensee will supply sufficient amount of perishable food upon arrival of the residents. LPA observed dining ware to accommodate a maximum capacity of six (6). All knives and sharps are observed to be locked in a kitchen cabinet and inaccessible to residents in care. The facility has one (1) new fire extinguisher, appeared to be full and serviced and were last purchased on 04/11/2024.
BEDROOMS: There are six (6) bedrooms designated for residents’ private use. All bedrooms are furnished with beds, dressers, chairs, night stands and required bedding and linen. The bedrooms have sufficient closet space and have sufficient lighting. Auditory alarms were tested and observed to be operational at 10:00AM. There is no bedroom designated for staff use. Facility will have awake staff at night. Emergency call buttons are available and will be provided to residents.
LAUNDRY ROOM: The laundry room is located in the separate locked area in the hallway between living room and bedrooms #5 and #6. The washer/dryer appear to be new and in good condition. Laundry supplies along with other chemical items are kept locked inaccessible under supervision when not in use.
Continue on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE: DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2024
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: INGOMAR SENIOR CARE
FACILITY NUMBER: 197610552
VISIT DATE: 07/17/2024
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BATHROOMS: Facility has six (6) bathrooms. At 10:15AM LPA observed all bathrooms are clean, in good repair and properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bars and non-skid mats in all bathrooms. Trash cans had closed tight fitting lids throughout. Water temperature was within regulation, and it was measured by an LPA at10:20AM to be at 110°F degrees. Bathrooms #3 and #4 are designated for Staff/Guests use only.
COMMON AREAS: The facility maintains a comfortable temperature at 72°F. The living room and dining area appeared clean and were properly furnished. In the living room cabinet there were puzzles, coloring books, crayons, and board games. No obstructions and or tripping hazards throughout the facility. An emergency exit plan/sketch is posted along the hallway with other posting requirements. Facility has no fireplace. No fire-arms observed or will be maintained on the premises.
MEDICATION ROOM: The medication and facility staff/resident files will be kept centrally stored and locked in the office area between the living room and the kitchen. First-aid kit was checked to be complete and has the new manual available. Facility will have four (4) staff members, two (2) for each shift (AM and PM).
SMOKE DETECTORS/CARBON MONOXIDE. Dual smoke detectors and carbon monoxide were located in the bedrooms and throughout the facility. At 10:50AM they were tested and observed to be operational.
SURROUNDING GROUNDS: The facility has gated entrance and sufficient yard space. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. The backyard is fenced. The facility is sharing the property with another licensed RCFE facility. There is no attached garage. LPA discussed the importance of maintaining the care and supervision to meet the needs of the residents. There are no bodies of water. The facility has land line located in the kitchen area checked by an LPA to be operational.

Component III: On 06/19/2024 the Licensee Yegeyan Nazar and Administrator Elen Bareghamyan. completed the Component III during Pre-Licensing visit at facility “Ingomar Assisted Living #197610556” at which time it was explained how to operate the facility within substantial compliance and had an opportunity to ask questions. Component III was waived based on LPA's discussion with the LPM.

Based on inspection and observation, the physical plant is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) and the applicant will be notified by the CAB Analyst when the license has been approved.

Exit interview was conducted and a copy of this report was provided to the Applicant/Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024
LIC809 (FAS) - (06/04)
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