195850290-10-27-2022-29-AS-SURA-CKLQU2-20221027122757

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850290
Report Date: 10/26/2022
Date Signed: 10/27/2022 12:28:45 PM

Document Has Been Signed on 10/27/2022 12:28 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:	MATEVOSIAN HOME		FACILITY NUMBER:	195850290
ADMINISTRATOR:	MATEVOSIAN, RAFAEL		FACILITY TYPE:	735
ADDRESS:	7500 BELLINGHAM AVE		TELEPHONE:	(818) 522-2222
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY: 4		CENSUS: 4	DATE:	10/26/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Rafael Matevosian		TIME COMPLETED:	12:30 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) Sandra Urena arrived at the facility at 10:48 a.m. to conduct a pre-licensing inspection. The LPA met with Applicant Rafael Matevosian. This is a Change of Ownership (CHOW) application from Matevosian Home (#197608025) to Matevosian Home (#195850290). The current capacity is for four (4) residents, the facility currently has four (4) residents. The fire clearance was granted on 09/09/2022 for ambulatory residents. From 10:55 a.m. to 11:45 a.m., the LPA and the applicant 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. KITCHEN: Kitchen knives are stored locked, and inaccessible to residents. The supply of perishable, and nonperishable food is adequate. The supply of dishes is adequate. Appliances in the kitchen were clean, and all appeared functional. There is an adequate supply of emergency food. The hot water temperature in the kitchen measured 108.2 degrees Fahrenheit. The fire extinguisher is mounted by dining room area, and was last serviced on May 1, 2022. BEDROOMS: The facility has five (5) bedrooms, four bedrooms for residents, and one for staff. Bedrooms are single occupancy. All residents’ bedrooms are furnished appropriately with clean linens, furnishings, and sufficient lighting. Continues on LIC809-C

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

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: MATEVOSIAN HOME	FACILITY NUMBER: 195850290
	VISIT DATE: 10/26/2022

NARRATIVE

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BATHROOMS: There are One and half (2) bathrooms designated for residents. The shower is equipped with nonskid surface. Grab bars were observed in the bathroom. The hot water temperature in the bathroom on the first floor measured at 110.2 degrees Fahrenheit, and second floor at 105.2 degrees Fahrenheit.

COMMON AREA: The common areas were appropriately furnished, and the lighting was adequate. The common areas, walls, flooring and furniture were checked for cleanliness and were found to be in good condition. Required postings were observed in the kitchen area poster board.

Emergency exiting plans/sketch, emergency telephone numbers, and other required postings are posted in the hallway and living room area.

MEDICATIONS: Medications are stored in the closet located in the hallway, and was observed to be locked, and inaccessible to residents in care. The first aid supplies were found on top of the refrigerator, including a first aid manual, and is located by the kitchen area.

FILES: Resident and staff records are stored in the closet located in the hallway, which was observed to be locked and inaccessible to residents in care.
LAUNDRY: The laundry area is located in room towards the recreation room.

EXTERIOR: The exterior passageways were clean, and clear of any obstructions. There is a covered patio area in the back yard with a sitting area for residents’ use.

Continues on LIC 809C...

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

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: MATEVOSIAN HOME	FACILITY NUMBER: 195850290
	VISIT DATE: 10/26/2022

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INFECTION CONTROL: The facility has a central entry point for symptom screening and a sanitation station for staff, residents, and visitors. The facility has an adequate supply of PPE and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

Applicant completed Component III for Adult and Residential (ARF) programs.

This report will be sent to the Centralized Application Bureau (CAB). The CAB Analyst will notify the applicant when the license has been approved. The applicant is aware that they are unable to operate under the new license number until they have been notified that the license has been approved by the CAB Analyst. Failure to comply could affect approval of the license.

Exit interview conducted with applicant, and the report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

LIC809 (FAS) - (06/04)

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