195850251-2-15-2023-29-AS-EPEI-CP3TK4-20230215134719

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850251
Report Date: 02/15/2023
Date Signed: 02/15/2023 01:47:52 PM

Document Has Been Signed on 02/15/2023 01:47 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:	VALLEY SENIOR CARE LIVING, INC		FACILITY NUMBER:	195850251
ADMINISTRATOR:	DANIELIAN, KHATCHIK		FACILITY TYPE:	740
ADDRESS:	8140 MATILIJA AVE		TELEPHONE:	(310) 666-2392
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91402
CAPACITY:	6	CENSUS: 0	DATE:	02/15/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Davit Hakobyan		TIME COMPLETED:	01:55 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 Analysts (LPAs) Emily Peraldi and Zabel Chochian conducted a pre-licensing visit to the above noted facility at 10:00 a.m. The LPAs met with applicant, Davit Hakobyan. This is a new facility. A Hospice Waiver has been requested and approved for six (6). The facility is one story. At 10:44 a.m., a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for six (6) ambulatory residents only. The facility has three (3) shared rooms, Room #1, #2, and #3. Resident rooms #1 and #3 have direct exits to the outside. The facility does not fire sprinklers. All resident rooms are set up with beds, nightstands, lamps, and closet space. The applicant will have chests of drawers and chairs for each room. 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. In addition, no bedroom was used as a passageway to another room, bath or toilet. There are no staff rooms and an awake night staff will be present. All rooms were free of odors. All window screens were clean and maintained in good repair. There are two (2) bathrooms in the facility, one in the hallway and one near the kitchen. The resident bathrooms have a shower and will have non-skid materials. One of the restrooms has shower with grab bars, the other one does not. The hot water temperature was tested in the bathrooms and the kitchen and was found to be within the range of 105F and 120F. The hot water temperature was measured as follows: bathroom #1= 113F, bathroom #2 = 115F and the kitchen – 112 *F. Resident and staff records are stored in a locked filing cabinet which is currently located near the dinning room. Medications are centrally stored in a locked cabinet in the kitchen or will be centrally stored in a filing cabinet near the dining room. The first aid supplies were not complete. The applicant will have current version of a first aid manual. They were stored in a filling cabinet near the dining area. 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: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

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: VALLEY SENIOR CARE LIVING, INC	FACILITY NUMBER: 195850251
	VISIT DATE: 02/15/2023

NARRATIVE

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Kitchen knives are stored in a locked drawer in the kitchen. 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. 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. The applicant will get a trash cans had tight fitting lid for the kitchen. Kitchen, laundry and house cleaning supplies are stored in a locked cabinet located inside the restroom. No flies or other vermin were observed.

The common areas 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. There was sufficient space to accommodate both indoor and outdoor activities. Night lights will be 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. However, the applicant stated that the facility is only for ambulatory residents. There is not a fireplace in the living room. Alarms on all exterior doors were engaged at the time of visit and functional. In addition, the physical plant is not consistent with the submitted facility sketch/floor plan. The applicant will submit a new facility sketch to include the garage/storage, and the laundry room. The facility had emergency lighting, which included flashlights. The applicant will have batteries prior to licensure. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit.

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. There is one fire extinguisher and it was fully charged and did not exceed the expiration date.

The laundry room can be accessed through the back patio and remains inaccessible to residents. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in one of the restrooms. Extra incontinence supplies are stored in a hallway closet. There will be a functioning telephone on the premises. The applicant will post the required postings near the dining area.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

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: VALLEY SENIOR CARE LIVING, INC	FACILITY NUMBER: 195850251
	VISIT DATE: 02/15/2023

NARRATIVE

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The exterior passageways were not clear of any obstructions. There is a covered patio area at the front and back of the house. The applicant stated that patio furniture was ordered for the front patio for resident use. The entire property is fenced. One side of the house is separated from the front yard and back by a gate. The applicant will remove the current locks on the front gate and replace it with a knob mechanism or self latch. There is a storage shed in the side of the house. There are not any bodies of water on the premises at the present time. The water fountain is emptied and inaccessible. The garage is not accessible from the house; the doors were locked. The garage was converted to a storage room.

The following items must be corrected prior to licensure.
- Outdoor passageways need to be free of obstruction. The tree on the side of the house will be removed
- The outside two (2) gates on the side of the house will be removed. And the front gate will with the lock will be replaced with self-latch and a spring.
- The facility sketch will be updated to reflect the converted garage and the laundry room. The physical plant needs to be consistent with the facility sketch/ floor plan.
- Rooms #1-3 need the following: chairs, and chest of drawers.
- Both restrooms need non-skid mats.
- Nightlights need to be present in the hallways outside non-private bathrooms.
- Kitchen needs a trash can with a tight-fitting lid.
- An operating telephone available to residents.
- A current first aid manual and tweezers (for the first aid kit).
- Required postings that need to be posted: Emergency exiting plans and telephone numbers, Facility Theft and Loss Program, Resident Personal Rights and Resident Council Rights.
- The dead bolt lock at the front entrance door and Room #3 door needs to be removed.
Submit proof of corrections by 02/24/2023, along with a copy of this report, to LPA Peraldi, so that your application may be completed.

At 12:50 p.m., Comp III was completed.

This report will be sent to the Centralized Application Bureau (CAB) once all corrections are received. 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.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

LIC809 (FAS) - (06/04)

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