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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850206
Report Date: 02/24/2023
Date Signed: 02/24/2023 02:27:56 PM


Document Has Been Signed on 02/24/2023 02:27 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:A'VILLAFACILITY NUMBER:
195850206
ADMINISTRATOR:HAKOBYAN, ANNAFACILITY TYPE:
740
ADDRESS:6532 GLORIA AVE.TELEPHONE:
(310) 435-1445
CITY:LAKE BALBOASTATE: CAZIP CODE:
91406
CAPACITY:6CENSUS: 0DATE:
02/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Anna Hakobyan - Administrator TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual. This annual had a specific emphasis on infection control practices and procedures. Upon arrival LPA met with Administrator Anna Hakobyan and explained the reason for the visit. There were no residents at the time of the visit.
At approximately 11:30, LPA 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.
Facility is a single-story residence and consists of a total of (5) bedrooms and (2) bathrooms designated for clients use. (1) bedroom (room #4) is designated for staff use and LPA observed it to be empty at this time. The carbon monoxide and smoke alarms were tested and all functioned properly. The fire extinguisher was fully charged and last purchased in December 2022. During physical plant tour LPA observed the required postings throughout the facility.
Kitchen:  LPA observed Kitchen  to be relatively clean at this time and the appliances and fixtures functional during the time of visit.  LPA observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects were observed stored in locked drawer to the right of the sink.   No Cleaning supplies and toxins were observed in this area at this time To the right of the kitchen was the laundry area. Cleaning supplies were observed to be stored and locked in cabinets above the washer and dryer and in a cabinet under the sink located in this area as well.   The supply of dishes, utensils, pots, pans and drinkware is adequate.  The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. 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.  No flies or other vermin were observed.
The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: A'VILLA
FACILITY NUMBER: 195850206
VISIT DATE: 02/24/2023
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LPA observed a sufficient supply of linen and  personal hygiene  supplies in the hallway closet right outside of bedroom #1 The resident bathroom(s) has a shower with non-skid materials.  The toilet and showers have grab bars.  The hot water temperature was tested in the bathrooms and the kitchen and was found to be within the range of 105*F and 120*F.
Common Areas:  These included the living room,  dining area and office area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Dining room furniture appeared to be relatively clean and functional at this time. Medications, first aid and facility files  are to be stored in locked cabinet outside of bedroom #1. LPA observed a locked cabinet that stored a sufficient amount of PPE, linen and extra medical supplies outside of bedroom #2Night lights were maintained in hallways and passageways to nonprivate 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. Alarms on all exterior doors were engaged at the time of visit and functional. The facility had emergency lighting, which included flashlights, or other battery powered lighting, and batteries.
Outdoor Area:  There was a shaded area with sufficient room for activities. LPA observed sufficient furniture designated for outdoor use. LPA also observed a pet tortoise.  There is a gated swimming pool located in the backyard.  Garage was accessible from the exterior of the building. Licensee opened garage and LPA observed building material, non-perishable foods, extra medical supplies and extra equipment and decorations for facility use. The exterior passageways were clean and clear of any obstructions.   The entire property is fenced with a gated  driveway. There is a door w/gate with a self-latching mechanism for persons to easily exit the property in the event of an emergency. Large building in rear of facility is still under construction. First observed during post licensing visit on 8/4/2022, Licensee stated they are building a storage unit. Licensee provided LPA with documentation of approved plans, permit and survey during that visit.
INFECTION CONTROL: During today’s visit, LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station. LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate at this time.

Exit interview conducted and report issued to the Administrator.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC809 (FAS) - (06/04)
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