195850317-1-19-2023-29-AS-SURA-CN8Q2Q-20230119104730

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850317
Report Date: 01/18/2023
Date Signed: 01/19/2023 10:48:34 AM

Document Has Been Signed on 01/19/2023 10:48 AM - 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:	STARLIGHT FACILITY INC.		FACILITY NUMBER:	195850317
ADMINISTRATOR:	TADEVOSYAN, NELLI		FACILITY TYPE:	740
ADDRESS:	7647 TUJUNGA AVE.		TELEPHONE:	(818) 378-7069
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY:	6	CENSUS: 0	DATE:	01/18/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Nelli Tadevosyan		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	The pre-licensing visit was conducted by Licensing Program Analyst (LPA), Sandra Urena. The LPA arrived at the facility at 09:40 a.m., and met with applicant Nelli Tadevosyan. This is a new facility application for a total of six residents, five (5) non-ambulatory, and one bedridden. Fire Clearance was approved on 11/18/2022 for one bedridden resident, and resident is allowed to reside in bedroom #3. At 09:45 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: A seven day supply of non-perishable food was available. The supply of dishes is adequate. Appliances in the kitchen were clean and all appeared functional. House cleaning supplies will be stored in locked cabinet under the sink. Hot water temperature was recorded at 118.2 Fahrenheit degrees. There were no pesticides or toxins stored near food, or preparation area. Trash cans did not have a tight-fitting lid. BEDROOMS: Facility has three (3) bedrooms for resident use. There is no bedroom available for staff use. Bedrooms are for double occupancy. Bedroom #3 is approved for one (1) bedridden resident. Lighting in the rooms appeared adequate. All bedrooms had adequate closet and drawer space for clothing and personal belongings. BATHROOMS: The facility has two bathrooms. Bathrooms are fully stocked with paper towels, and liquid hand soap. The showers have non-skid surface mats. Hot water temperatures were recorded in Fahrenheit degrees as follows:117.6 degrees for bathroom #1, and 118.2 degrees for bathroom in bedroom #3. Hand washing signs were visible and posted. Toilets will be equipped with adjustable handlebars/Safety toilet rails. Continues on LIC 809C...

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

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: STARLIGHT FACILITY INC.	FACILITY NUMBER: 195850317
	VISIT DATE: 01/18/2023

NARRATIVE

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COMMON AREAS: The common areas were appropriately furnished, and the lighting was adequate. There
is a television in the living room area.

-Door leading to bedrooms, needs a foot stop installed to keep it open.

-The first aid supplies were complete, including a thermometer. The first aid kit is located in a cabinet in the kitchen area medications will be stored in locked cabinet located in the kitchen.

-Residents, and staff records and will be stored and locked in file cabinet located in the garage.

-The facility’s smoke/carbon monoxide alarm systems are hard wired. All rooms were tested, and all
smoke/carbon monoxide alarm systems were in operating condition. A fire extinguisher is properly charged, and mounted on the wall in the kitchen area.

-The laundry area is located inside the garage. The supply of linens is sufficient to permit changing weekly or more often as needed to ensure use of linens at all times.

-An operating telephone was not available for resident use. Per applicant, the line will be activated on 01/19/2023.

-At the time of the visit, the only ramp accessible for residents to exit the facility to the outdoor area, is located by bedroom #3. A ramp for residents’ use will be installed to allow access to residents from outdoor to indoors and vice versa area.

Infection control, and other posters are posted in the living room area.

The exterior passageways were clean, and clear of any obstructions. The back patio is furnished with outdoor
furniture for residents’ use, and shade is available. The building has a central entrance for visitors. Fire emergency gates are clear of obstructions. The facility has a gated pool, and is inaccessible to residents.

Continues on LIC 809C...

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

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: STARLIGHT FACILITY INC.	FACILITY NUMBER: 195850317
	VISIT DATE: 01/18/2023

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-The backyard area has a slope area leading to a gate facing the alley, behind the house. The area needs to be gated to prevent residents wondering to this slopped area, and to prevent falls.

-There are two protruding screws sticking out of a wall adjacent to the bedroom #3 that will need to be removed/covered to prevent accidents.

-Applicant stated that a personal vehicle will be utilized to transport residents.

Pre-Licensing is incomplete with deficiencies to be resolved. During the inspection, the LPA, and applicant
observed the following corrections needed, prior to being licensed:

1. Door leading to bedrooms needs a foot stop installed to keep it open.
2. An operating telephone was not available for resident use. Per applicant, the line will be activated on 01/19/2023.
3. The backyard area has a slope area leading to the gate facing the back house alley. The area needs to be gated to prevent residents wondering to this slopped area and to prevent falls.
4. There are two protruding screws sticking out of a wall adjacent to the bedroom #3 that will need to be removed/covered to prevent residents from any accidents.
5. A ramp for residents’ use will be installed to allow access to residents to the outdoor area.
6. Purchase trash cans with a tight-fitting lid.

The applicant completed Component III Orientation.

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.

Exit interview was conducted and reviewed with applicant Nelli Tadevosyan . A copy of the report was
issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

LIC809 (FAS) - (06/04)

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