195850178-10-25-2023-29-AS-EPEI-CWXS36-20231025133038

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850178
Report Date: 10/25/2023
Date Signed: 10/25/2023 01:31:03 PM

Document Has Been Signed on 10/25/2023 01:31 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
WOODLAND HILLS N.ASC, 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: 5	DATE:	10/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Chellsea Labestre		TIME COMPLETED:	01:35 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) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 11:25 a.m., the LPA met with staff and explained the reason for the visit. At 11:39 a.m., the LPA spoke with the Administrator over the telephone. The Administrator was not available during the time of the visit and authorized staff, Chellsea Labestre to sign the report. At 12:04 p.m., the LPA, along with staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. KITCHEN: The LPA observed the kitchen/dining area. Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 12:05 p.m., hot water measured at 105.1-degree Fahrenheit. Medications and first aid kits are located in a locked cabinet near the kitchen area. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in a cabinet near the kitchen area. The laundry units are located near the kitchen area. BEDROOMS: The facility is a single-story residential home with nine (9) bedrooms, six (6) for resident's use and three (3) for staff. The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. RESTROOMS: The facility has eight (8) restrooms, six (6) for resident use and two (2) for staff/ public use. Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. Starting at 12:11 p.m., hot water measured between 105.7 and 112.0-degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels. OUTDOOR SPACE: At 12:12 p.m., the LPA observed the back patio and side patio which has a covered outdoor area for resident use. There gates on the side of the house and the back designated for an emergency exits. There are no bodies of water on the premises. Continued on LIC 809-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

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

FACILITY NAME: MONOGRAM VILLA	FACILITY NUMBER: 195850178
	VISIT DATE: 10/25/2023

NARRATIVE

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COMMON AREAS: The LPA observed the common area to be relatively clean and properly furnished. The LPA observed the fire extinguisher to be fully charged and last serviced on 05/05/2023. At 1:12 p.m., fire alarms/ carbon monoxide detectors were tested and functioned properly. Night lights were present in the hallway. The LPA observed an activities cart near the dining room for resident use.

Between 12:27 p.m. and 12:54 p.m., the LPA interviewed five (5) residents and two (2) staff.

Due to time constraints the LPA will return to complete the annual at a later date.

No deficiencies were observed at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC809 (FAS) - (06/04)

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