195850327-5-15-2023-29-AS-CYEE-CRS2KG-20230512172754

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850327
Report Date: 05/12/2023
Date Signed: 05/15/2023 08:27:57 AM

Document Has Been Signed on 05/15/2023 08:27 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	FARMDALE VILLA, INC.		FACILITY NUMBER:	195850327
ADMINISTRATOR:	PARANDZEM KONSTANYAN		FACILITY TYPE:	735
ADDRESS:	6237 FARMDALE AVENUE		TELEPHONE:	(818) 620-0955
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY: 6		CENSUS: 0	DATE:	05/12/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Parandzem Konstanyan, Applicant		TIME COMPLETED:	05:30 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) Christine Yee conducted an announced Prelicensing Visit to ensure the home meets Title 22 requirements. LPA Yee met with Parandzem Konstanyan and Yuliya Asatryan, Applicants. The home is a single family home consisting of a living room, dining room, kitchen, family room, office/storage room, 5 bedrooms and 2 full bathrooms. The home is fire cleared for 5 non-ambulatory and 1 bedridden clients. Per tour of the home the following was observed: the facility has a land line phone that rings directly into the home. The telephone number is (818)691-3409. the living room and dining room contained the appropriate furniture the kitchen has a refrigerator, dish washer and stove that were operational. Plates, cups, glasses, pots, pans and utensils were observed. the washer and dryer located in the kitchen were operational. the non-perishable food in the pantry was reviewed and needs to be supplemented with breakfast foods such as cereal, oatmeal, pancake mix, additional pasta sauces, canned vegetables and proteins. There were no perishable foods observed. Applicant will also purchase a 2 day supply of perishable foods prior to the

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FARMDALE VILLA, INC.	FACILITY NUMBER: 195850327
	VISIT DATE: 05/12/2023

NARRATIVE

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acceptance of the first client
Medications and sharp knives will be stored in a locked kitchen cabinet and drawer
the only fire extinguisher located by the kitchen was last tested on 11/29/22.
Bedroom #1 is a double occupancy room and has 2 single beds, 2 chairs, 2 lamps and 2 night stands. There were no dressers. The 2 beds were missing mattress pads.
Bedroom #2 has a single bed, 2 night stand, lamp and a chair. Applicant will replace one of the night stands with a dresser. The bed is missing a mattress pad. The curtains on the French door needs to be shortened or changed to ensure it is not a tripping hazard.
Bedroom #3, designated for bedridden, contains a single size day bed, dresser, night stand, chair and lamp. The required linens were observed
Bedrooms #4 and Bedroom #5 both have a queen size bed, a night stand, a lamp and a closet. There were no dressers. The required bed linens were observed.
All the windows and doors had the appropriate window dressing for privacy.
Hygiene products for resident use was observed
First aid kit and scissors was observed. No First Aid Manual was observed.
The water temperature was tested in the front and back bathrooms. The temperature reading for the front bathroom read 119.90 and the back bathroom read 114.4 degrees Fahrenheit.
The 2 bathrooms have non-skid mats and grab bars
night lights were observed in the hallway and in the residents rooms
the interconnected smoke and carbon monoxide detectors were tested and were operational

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FARMDALE VILLA, INC.	FACILITY NUMBER: 195850327
	VISIT DATE: 05/12/2023

NARRATIVE

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the Applicant with ensure that liability insurance in the amount of one million dollars per occurrence for total aggregate of three million dollars is purchased prior to opening.
The back yard has a covered gazebo furnished with a table and chairs
The front and backyard needs general cleaning to remove discarded items. Planters, buckets, hedge clippers, picnic chairs need to be stored away.
Trash cans were observed overflowing with discarded trash and cardboard boxes

The following corrections need to be made prior to licensure:

Extra non-perishable need to be purchased to supplement food already in the facility and perishable foods need to be purchased prior to accepting the first client
extra bed linens need to be purchased to allow for weekly and daily changing as needed
Hand towels and wash clothes need to be provided for client use and for changing
Mattress pads needs to be provided for client use in bedroom #1, #2
Dressers meeting Title 22 requirements need to be provided in bedroom #1, #2, #4 and #5
Curtain in bedroom #2 needs to be adjusted/change to prevent tripping
A first aid manual needs to be available in the facility
cleaning solutions, rubbing alcohol and laundry detergent stored in the pantry needs to be relocated from the food pantry
Items placed along the hallways and doorways, such as the water cooler, scratching post, water bowl need to be relocated
General cleaning is needed in the front and backyard. Items not being used should be stored away
Trash cans need to be emptied to allow lids to be tightly sealed

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FARMDALE VILLA, INC.	FACILITY NUMBER: 195850327
	VISIT DATE: 05/12/2023

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 26 27 28 29 30 31 32	the stained curtain in bedroom #5 needs to be washed Applicants will advise LPA Yee once the corrections have been completed for a return visit. Component III was conducted with Parandzem Kostanyan and Yuliya Asatryan Exit Interview was conducted.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

LIC809 (FAS) - (06/04)

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