195850263-8-26-2022-29-AS-BBAI-CHNR7N-20220826124638

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850263
Report Date: 08/26/2022
Date Signed: 08/26/2022 12:49:17 PM

Document Has Been Signed on 08/26/2022 12:49 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:	PRIME SENIOR LIVING, INC		FACILITY NUMBER:	195850263
ADMINISTRATOR:	NSHANIAN, HERMINE		FACILITY TYPE:	740
ADDRESS:	8123 PASO ROBLES AVE		TELEPHONE:	(818) 913-3309
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	91406
CAPACITY: 6		CENSUS: 0	DATE:	08/26/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Levon Najarian - License		TIME COMPLETED:	01:00 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) Brian Balisi conducted a pre-licensing visit to the above noted facility. The LPA met with applicant Levon Najarian This is a new facility. A dementia program was included in the plan of operation. A Hospice Waiver has been requested. The facility is one story. At approx. 10am, a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for 6 ambulatory residents; The facility has (2) private resident bedrooms, Rooms #1 and #4 and (2) shared room(s), Room #2 and #3. All resident rooms do not have direct exits to the outside. There are no fire sprinklers in facility. All resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. 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. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. There are no staff rooms - "awake night staff only. All rooms were free of odors. All window screens were clean and maintained in good repair. There is (1) one bathroom in the hallway and (1) one bathroom in Resident room #1. The resident bathroom(s) has a shower with non-skid materials. The toilet and shower have grab bars. The hot water temperature was tested in the bathrooms and the kitchen and was found to be within the range of 105F and 120F. Resident and staff records are stored in filing cabinet, which is currently located in the kitchen. Medications are centrally stored in a locked filing cabinet in the kitchen. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. They were stored in the filing cabinet as well. Continued on 809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

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: PRIME SENIOR LIVING, INC	FACILITY NUMBER: 195850263
	VISIT DATE: 08/26/2022

NARRATIVE

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continued from 809
Kitchen knives are stored in a locked cabinet to the right of the stove in the kitchen. Stove burners are rendered inaccessible to the residents by removing them when not in use. 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. Trash cans had tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in a locked hallway closet. No flies or other vermin were observed.

The common areas were appropriately furnished, and the lighting was adequate. There are televisions 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 were maintained in hallways and passageways to non private bathrooms. There is a fireplace in the living room. It is screened and there are no tools. Alarms on all exterior doors were engaged at the time of visit and functional.
In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included flashlights, or other battery powered lighting, and batteries. 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 are (2) fire extinguishers throughout the house. They are fully charged and do not exceed the expiration date.
Hot water was tested in each bathroom, which included the resident bathroom(s) and any common bathrooms, in addition to the kitchen; and, the hot water ranged from 105 to 120 degrees Fahrenheit. The laundry area is located in the kitchen The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in the hallway closet Extra incontinence supplies are stored in hallway closet as well. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted at the entrance and outside of every room. The emergency telephone numbers are posted in white board in common area. Other required postings are posted on the white board as well.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

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: PRIME SENIOR LIVING, INC	FACILITY NUMBER: 195850263
	VISIT DATE: 08/26/2022

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Continued from 809-C

The exterior passageways were clean and clear of any obstructions. There is a covered patio area at the back of the house with tables and chairs where residents can sit. The entire property is not fenced. The back and sides of the house are separated from the front yard by gates at the north and south side passageways. The gate to the driveway is moved manually. There is a door w/gate with a self-latching mechanism for persons to enter the front yard. There is a locked detached garage used for storage shed at this time located in the backyard. Extra storage in the rear exterior of the garage was observed empty at this time. There are no bodies of water on the premises at the present time. The garage is not accessible from the house; the doors were locked.

Component III was conducted in conjunction with the visit.

No corrections required on a pre-licensing visit at this time. Exit interview conducted. Report issued and sent via email.

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.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

LIC809 (FAS) - (06/04)

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