195850080-1-14-2021-29-AS-EMIR-BXA22N-20210114160102

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850080
Report Date: 01/14/2021
Date Signed: 01/14/2021 04:01:06 PM

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:	VENTURA CANYON CARE		FACILITY NUMBER:	195850080
ADMINISTRATOR:	SUKIASYAN, ARMAN		FACILITY TYPE:	740
ADDRESS:	7938 VENTURA CANYON AVE		TELEPHONE:	(818) 205-6365
CITY:	PANORAMA CITY	STATE: CA	ZIP CODE:	91402
CAPACITY:	6	CENSUS: 0	DATE:	01/14/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Arman Sukiasyan		TIME COMPLETED:	04:00 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) Eva Miller conducted a Pre-Licensing Inspection with Applicant Representative Arman Sukiasyan. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted virtually with the use of "FaceTime". An Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on 8/10/20. A Fire Clearance was approved for a maximum capacity of six (6) residents, all of which may be non-ambulatory and 1 of which may be bedridden, on 06/19/20. The proposed physical plant is a one (1) story single family dwelling located in a residential neighborhood of Panorama City, CA. A tour of the physical plant was conducted and the following observed: KITCHEN: Appliances and fixtures appeared clean and functional. There was sufficient nonperishable food to accommodate a maximum capacity of 6 residents for (seven) 7 days. There was sufficient dining and cook ware to accommodate a maximum capacity of 6 Residents. Medications are stored in locked cabinets and kept inaccessible to residents. The first aid kit is stored in the kitchen. There were no visible immediate hazards or discrepancies observed. BEDROOMS: There are four (4) Bedrooms, all of which are designated for Resident use. Bedrooms #1 and 4 are furnished for double occupancy. Bedrooms #2 and 3 are furnished for single occupancy. Bedroom #3 is designated as per the Fire Clearance for Bedridden use. There was appropriate furniture, bedding and linens. There were no visible hazards or discrepancies observed.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Eva Miller	TELEPHONE: (818) 326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2021

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VENTURA CANYON CARE	FACILITY NUMBER: 195850080
	VISIT DATE: 01/14/2021

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: There are three (3) full Bathrooms. There is a bathrooms located inside Bedroom #1 and is designated for the occupant of Bedroom #1 only. This bathroom requires the installation of grab bars for both the toilet area and shower. There is a bathroom located next to bedroom #2 that is designated for both Resident and Staff use. There is a bathroom located next to Bedroom #3 that is designated for both Staff and Resident use. This bathroom requires the installation of grab bars in the shower area. All Bathrooms were supplied with appropriate paper and hygiene products.

COMMON AREAS: These include the Living Room and Dining Room. The common areas were furnished to accommodate a maximum capacity of six (6) residents. There were no immediate hazards observed..

LAUNDRY: Laundry appliances are located outside on the covered patio and are kept inaccessible to residents..

SURROUNDING GROUNDS: The Front Yard includes a driveway, paved walkways and landscaped areas. The backyard is fenced and includes paved walkways, landscaped areas, a patio, furniture appropriate for outdoor use and shade. There are handicapped accessible ramps. There were no visible immediate hazards or deficiencies.

COMPONENT III ORIENTATION; A Component III Orientation was conducted.

The following will be required before a license can be issued:

A revised Facility Sketch - Yard (LIC 999) that documents the water shut-off and overall yard size. Please note it is a best practice to include a compass.
A revised Facility Sketch - Floor Plan (LIC 999) that re-labels the "Office" as a "Storage Room"
The installation of Grab Bars as described above.

A copy of the Licensing Report was provided via email for signature and return.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Eva Miller	TELEPHONE: (818) 326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2021

LIC809 (FAS) - (06/04)

Page: 2 of 2