Routine inspection·May 8, 2025

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual visit. Upon arrival LPA met with the Administrator Anna Hakobyan and explained the reason for the visit. The facility serves level 3 clients from North Los Angeles County Regional Center. LPA Urena and the Administrator 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 facility is a single-story residence and has (2) private bedrooms and one (1) shared bedroom for resident use and one (1) bedroom designated for staff. At the time of the visit, two (2) residents were attending day program, and two (2) residents were observed at the facility. The facility smoke alarm system is hard wired. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. Fire extinguisher was observed fully charged and purchased on March 12, 2025. COMMON AREAS: Including the dining and living room, these were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment, games and/or activity supplies in the living room and dining area. Night lights were maintained in hallways and passageways to non-private bathrooms. All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. There is a functioning telephone on the premises. Required postings were observed by the entrance hallway. A chimney was observed in the living room area. The chimney was covered and non-functional at the time of the visit. Continues on LIC 809C... KITCHEN : Knives and sharp objects are stored in the top drawer to the right of the sink. LPA observed it to be inaccessible to residents in care. The supply of dishes, utensils, pots, pans and drink ware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen, laundry, and house cleaning supplies are stored in the garage inaccessible to residents in care. The first aid kit was observed in the kitchen, and it is complete and included a current version of a first aid manual. BEDROOMS: All rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen, which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. All rooms were free of odors. All window screens were clean and maintained in good repair. Each bedrooms have its own supply of linens stored in the closet. BATHROOMS: There is one (1) bathroom in the common area designated for resident use. Hot water temperature measured at 111.5 F degrees at the time of visit. The resident’s bathroom has a shower with non-skid materials and mats. The toilet and shower have grab bars. The bathroom nearest to the kitchen is designated as a staff restroom. The hot water temperature was tested in the staff bathroom and in the kitchen and was found to be within the range of 105*F and 120*F degrees. Bathroom located in master room is not in use, inside there are PPE supplies, emergency supplies, linen and extra towels. This room has a “For Employees Only” sign and it is locked at all times. The LPA had a conversation with the Administrator about the facility sketch, which describes the master bathroom designated as a bathroom and not for storage use. The Administrator stated that an updated facility sketch was submitted to the Department for approval. The Administrator will provide proof of the approval of the updated facility sketch. LAUNDRY ROOM: Located between the garage and the kitchen. Personal hygiene items (shampoos, soaps) were adequate and are stored in a cabinet above the washer and dryer. Continues on LIC 809C... OUTDOOR SPACE : At the time of the visit, the back patio area of the house had a table and chairs out of reach. The Administrator was advised to bring the patio table, chairs and umbrella to the top area of the patio for residents’ use. The front of the house has a shaded area for residents use. During today’s visit, LPA Urena observed an accessory dwelling unit (ADU) in the back patio. Per the Administrator, an accessory dwelling unit (ADU) was constructed by the property owner. Furthermore, LPA Urena advised the Administrator that a barrier will have to be added to separate the facility from the ADU and to ensure that the fence will meet the fire safety guidelines. The barrier has to be completed in 15 days (05/23/2025) from today’s date. On 05/10/2024, LPA Valeria Conway conducted the required annual inspection and requested that the administrator keep LPA Conway updated with the progress of the construction and submit an updated facility sketch upon completion. Discussion was also held regarding staff prioritizing safety measures to ensure all residents are safe during the construction. Additionally, LPA Conway also informed administrator that any individual that is living in the ADU should be fingerprinted and associated to the facility prior to residing. There are no bodies of water on the premises at the present time. Garage is attached to the home and was observed to be inaccessible to residents in care. LPA observed the garage locked and to store emergency food supplies, extra non-perishable foods, PPE, medical supplies and incontinent supplies. RECORDS: Records review began at 12:45 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. MEDICATIONS: Medications review began at 01:45 p.m.; medications are centrally stored and locked in a cabinet in the kitchen area next to the refrigerator; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. The LPA reviewed the following documents: - LIC500 Personnel Report - LIC9020 Client Roster - Certificate of Liability of Insurance - Emergency Drill Logs No citations were issued. Exit interview conducted. A copy of the report was issued.