195850178-9-27-2021-29-AS-EPEI-C79UJ3-20210927153651

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850178
Report Date: 09/27/2021
Date Signed: 09/27/2021 03:38:10 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:	MONOGRAM VILLA		FACILITY NUMBER:	195850178
ADMINISTRATOR:	KRBASHYAN, AZNIV ANGELA		FACILITY TYPE:	740
ADDRESS:	5536 TYRONE AVE		TELEPHONE:	(818) 808-7792
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91401
CAPACITY:	6	CENSUS: 0	DATE:	09/27/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Angela Azniv Krbashyan		TIME COMPLETED:	03:45 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	At 12:45 p.m., Licensing Program Analyst (LPA), Emily Peraldi, conducted a pre-licensing visit to this property with applicant representative Angela Azniv Krbashyan. The applicant has obtained fire clearance for a total capacity of six (6) bedridden residents. LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. Between 12:55 p.m.- 2:00 p.m. LPA, along with applicant toured the facility. At 12:55 p.m., LPA toured the kitchen area. The facility will have seven (7) day supply of non-perishable food. Appliances and all equipment appear to be clean and in good repair. Kitchen knives are stored in a locked cabinet. The kitchen has a sufficient supply of plates, cups, cook ware and utensils. The freezer and refrigerator are at proper temperature range. At 1:50 p.m. hot water measured at 139.5 degrees Fahrenheit. Licensee will prominently identify hot water by warning signs and send a picture to the LPA. Cleaning supplies and disinfectants are stored and inaccessible in the kitchen area. At 1:10 p.m. fire alarms and carbon monoxide detectors were tested and functioned properly. LPA observed two fire extinguishers to be fully charged and purchased on 02/15/2021. There are six (6) single occupancy bedrooms for resident use. There are two (2) staff rooms and one (1) storage room. Each bedroom is equipped with clean mattresses, pillows, bedding, a dresser and closet space. There is sufficient supply of linens, including blankets, bath towels and wash cloths. Bedrooms have sufficient lighting. Each resident bedroom has its own private bathroom. Bathrooms have sufficient paper products. The lights in the main hallway can be dimmed and used as night-lights. At 1:55 p.m. hot water measured to 115.3 Fahrenheit. Continued on LIC 809-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021

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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MONOGRAM VILLA	FACILITY NUMBER: 195850178
	VISIT DATE: 09/27/2021

NARRATIVE

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Continued from LIC 809.

The living areas and dining areas are clean and properly furnished. All window screens and coverings are in good repair. Facility will have a working telephone for resident use. Facility will have activity supplies such as magazines and board games. Licensee will send LPA proof of facility telephone and activity supplies.
Medications will be stored and locked in near the kitchen area. First aid kit was observed to have bandages, thermometer, scissors, and tweezers. Licensee will purchase a current first aid manual and notify LPA. Laundry area is located near the kitchen area.

The facility has a receptionist area that will serve as a central entry point for universal screening. Alcohol-based hand sanitizer is available upon entry. Facility records will be stored and locked in a cabinet located in the receptionist area. Signs will be posted throughout the facility to promote handwashing, and cough/sneeze etiquette. Facility will have an adequate 30-day supply of Personal Protection Equipment (PPE).

There will be adequate supply of emergency water, along with emergency nonperishable food items kept in the storage room. There will be no firearms/ammunition stored on the property.

The facility has required postings, including emergency exit plan, Licensing Complaint Poster, Client Personal Rights, and Facility Theft and Loss Program.

The exterior passageways were clean and clear of any obstructions. There are bodies of water on the premises at the time of the visit. The front of the facility has an operating waterfall. Licensee will empty out the water and cover the waterfall with rocks and plants. LPA observed the back and side patio, which has a covered outdoor area for resident use. There is a gate on the side of the house designated for an emergency exit. Physical plant is consistent with the submitted facility sketch/floor plan.

Continued on LIC 809-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021

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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MONOGRAM VILLA	FACILITY NUMBER: 195850178
	VISIT DATE: 09/27/2021

NARRATIVE

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Continued from LIC 809-C.

During the inspection, the LPA observed the following corrections needed prior to licensure:
- Bathrooms need a trash cans with tight fitting covers.
- 30 days of PPE needed.
- Emergency water needed.
- Facility telephone for resident use needed.
- A current first aid manual.
- Facility needs activity supplies and equipment.
- Water fountain to be drained and filled with rocks and plants.
- A warning sign for the kitchen hot water.

At 2:32 p.m. Comp III conducted.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview conducted. A copy of the report was provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021

LIC809 (FAS) - (06/04)

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