565850389-11-18-2024-29-AS-MARO-DB5UMZ-20241118144311

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850389
Report Date: 11/18/2024
Date Signed: 11/18/2024 02:43:20 PM

Document Has Been Signed on 11/18/2024 02:43 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	GRAND SENIOR LIVING, THE		FACILITY NUMBER:	565850389
ADMINISTRATOR/ DIRECTOR:	VERONIKA YEBEYAN		FACILITY TYPE:	740
ADDRESS:	4752 FORT WORTH DRIVE		TELEPHONE:	(818) 408-9408
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY: 6		CENSUS: 6	DATE:	11/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:40 AM
MET WITH:	Hovsep Solakyan		TIME VISIT/ INSPECTION COMPLETED:	03:00 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 Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit. This will be the first annual from their Pre-Licensing visit on 10/30/2023. Upon arrival, there were two (2) staff and six (6) residents present. The LPA was greeted by facility staff who contacted the Licensee Representative via telephone. The Licensee Representative, Hovsep Solakyan arrived at approximately 9:55 a.m. Entrance interview conducted.

Starting at 10:00 a.m., the LPA along with the Licensee Representative toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: The LPA inspected the kitchen/food service area at 10:15 a.m. Knives and sharps were observed locked and inaccessible in a kitchen drawer. Cleaning supplies were observed under the kitchen sink locked and inaccessible to resident in care. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates.

COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. The LPA observed several fire extinguishers to be fully charged with a date of 06/20/2024. At 10:20 a.m., the smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. Required postings were observed throughout the common space. Activities were observed in the living room. There is a working telephone on premises. Cameras observed in the common areas.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024

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 3

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GRAND SENIOR LIVING, THE	FACILITY NUMBER: 565850389
	VISIT DATE: 11/18/2024

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

Report Continued from LIC 809...

RESTROOMS: There are two (2) restrooms for resident use. Bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. Starting at 10:05 a.m., the hot water temperature was measured in both bathroom and they measured 112 degrees Fahrenheit which is between the required range of 105 and 120 degrees Fahrenheit.

BEDDROOMS: There are six (6) bedrooms for resident use. All resident bedrooms are designated as private rooms. All resident rooms were observed to be furnished appropriately with linens, appropriate furnishings, and sufficient lighting. LPA observed a staff bedroom on premises. The LPA observed a closet in the hallway with additional clean linens and towels for resident use.

GARAGE: The garage was locked and inaccessible to residents at the time of the visit. There is an additional refrigerator with perishable food, in good condition. The LPA observed an adequate amount of emergency food and water. Additional cleaning supplies are kept in the garage locked and inaccessible to residents in care.

BACKYARD: The backyard has a covered patio area with patio furniture for resident use. LPA observed a locked shed with a washer and dryer. All passageways were observed to be clear of any obstructions. There are two (2) side gates with latching mechanisms. No bodies of water noted at the time of the visit.

RECORDS: LPA reviewed Resident Records at 10:35 a.m. and Personnel Records at 11:20 a.m.

Six (6) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GRAND SENIOR LIVING, THE	FACILITY NUMBER: 565850389
	VISIT DATE: 11/18/2024

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

Report Continued from LIC 809C...

Four (4) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate yearly training. All records were in order.

Administrator’s Certificate is valid until 04/02/2025.

During today’s inspection, the LPA conducted interviews with two (2) staff and one (1) resident.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control plan. The facility’s policies and procedures as it pertains to infection control are adequate. LPA also reviewed the facility's emergency disaster plan, which was observed to be complete and recently reviewed/updated. Emergency disaster drills conducted quarterly as per regulation; the last one being a fire drill which was conducted on 10/30/2024.

MEDICATIONS: Medications review began at approximately 12:05 p.m. The medications are locked in a file cabinet inside the garage. LPA observed a locked mini refrigerator with resident’s medications. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications are labeled and checked for expiration dates. Medications appeared to be given as prescribed at the time of the visit.

No citations issued. Exit interview conducted. A copy of the report were provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3