198603127-3-6-2022-28-AS-NMAN-CC7SMQ-20220304130020

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603127
Report Date: 03/04/2022
Date Signed: 03/06/2022 10:08:18 PM

Document Has Been Signed on 03/06/2022 10:08 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	ALAMEDA BOARD & CARE		FACILITY NUMBER:	198603127
ADMINISTRATOR:	AVETISYAN, ARMENUHI		FACILITY TYPE:	740
ADDRESS:	1129 ALAMEDA AVE		TELEPHONE:	(213) 595-2777
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91201
CAPACITY: 6		CENSUS: 6	DATE:	03/04/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Staff Armine Oganesyan and Administrator Yelena Amirjanyan		TIME COMPLETED:	01:00 PM

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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced Required One (1) year - Inspection to this facility. Upon arrival, LPA met with Staff Armine Oganesyan. Administrator Yelena Amirjanyan arrived shortly after, and assisted with the visit. The purpose of the visit was explained. The facility is licensed to serve 6 (six) ambulatory residents ages 60 and over of which 1 (one) may be bedridden. Facility is approved to retain 2 (two) residents on hospice. The facility cares for elderly residents with dementia.
LPA Nune Margaryan inspected the physical plant including but not limited to the kitchen, dining and living room, bedrooms, bathrooms, laundry area, and outside areas of the facility to ensure compliance with Title 22 regulations. LPA also conducted the infection control domain tool.

There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask upon entrance and during visit.

LPA inspected the interior and the exterior of the facility with the Administrator including but not limited to: living /dinning room, office / storage room, kitchen, three (3) resident bedrooms, three (3) bathrooms, laundry located outside, backyard and garage. All indoor and outdoor passageways are free of obstruction.

Bathrooms and bedrooms were clean and in good repair. There is a locked storages for medications in the kitchen. The common areas including the living / dining room are clean and have the required furniture. The backyard has a shaded area and sitting area. In the back yard right next to shaded / sitting area LPA observed cabinet which contains cleaning supplies / chemicals. It was not locked or inaccessible to residents. The facility has camera in the leaving / dining area only.

Continue 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022

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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALAMEDA BOARD & CARE	FACILITY NUMBER: 198603127
	VISIT DATE: 03/04/2022

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All residents bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space. Both bathrooms were toured. Bathrooms have the required grabs bars and non-skid mats. The hot water was 117.5 and 118.2 degrees which is within the required 105 - 120 degrees. LPA observed fire extinguisher near the kitchen which was fully charged. Smoke detectors were observed throughout the facility. First-aid Kit is complete and located in the kitchen.

LPA reviewed residents files to confirm emergency contact is updated. LPA also reviewed staff files to confirm health screenings and fingerprint clearances. All staff files reviewed were fingerprint cleared. Residents' medications were reviewed. Medications are documented properly and stored appropriately.

The deficiency cited is documented on the attached 809D. A copy of the report and appeal rights will be provided to Administrator.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/06/2022 10:08 PM - It Cannot Be Edited

Created By: Nune Margaryan On 03/04/2022 at 12:10 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALAMEDA BOARD & CARE	FACILITY NUMBER: 198603127
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation , the licensee did not comply with the section cited above. In the back yard right next to shaded / sitting area LPA observed cabinet which contains cleaning supplies / chemicals such as Awesome spray, Clorox spray. It was not locked or inaccessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/04/2022
	Plan of Correction
1 2 3 4	During the visit, Administrator immediately locked the cabinet and make inaccessible to residents. No further action needed.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Wei Siew Ho

LICENSING EVALUATOR NAME:

Nune Margaryan

LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022

LIC809 (FAS) - (06/04)

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