195850356-9-7-2023-29-AS-SURA-CVFKC6-20230907074633

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850356
Report Date: 09/06/2023
Date Signed: 09/07/2023 07:47:59 AM

Document Has Been Signed on 09/07/2023 07:47 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	PARADISE SENIOR HOME		FACILITY NUMBER:	195850356
ADMINISTRATOR:	DAVTYAN, KNARIK		FACILITY TYPE:	740
ADDRESS:	7639 ALCOVE AVE		TELEPHONE:	(818) 601-0013
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY:	6	CENSUS: 0	DATE:	09/06/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Knarik Davtyan		TIME COMPLETED:	03:12 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 conducted a pre-licensing visit to the above noted facility. The LPA met with applicant, Knarik Davtyan. This is an application for a new facility. A dementia program was included in the plan of operation. A Hospice Waiver has been requested. At 10:15 a.m., the LPA and the applicant conducted a physical plant tour inside and out to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility is a one-story dwelling. An approved fire clearance was received on 07/14/2023, clearing them for five (5) non-ambulatory residents; and one (1) of bedridden resident. KITCHEN: Kitchen knives are stored in a locked cabinet in the kitchen. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at below zero degrees Fahrenheit (0F) and the refrigerator was maintained at thirty degrees Fahrenheit (30F) 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 and locked in a top kitchen cabinet and the garage area. No flies or other vermin were observed. BEDROOMS: The facility has two (2) private residents’ bedrooms, Rooms # 1 and 4; and two (2) shared room(s), Room # 2 and 3. One residents’ bedroom, Room # 1 has a direct exit to the outside. The bedroom’s sliding door needs to be flushed with the floor for easy transfer from bedroom to outdoor area. Private bedroom # 1 has been approved and cleared for one bedridden resident. Bedroom #1 did not have a bed. Shared bedroom # two (2) did not have two beds. Private bedroom #3 has one bed. Shared bedroom #4, has one bed; needs one more bed. All bedrooms were set up nightstands, lamps, chairs and closet space. Continues on LIC 809C...

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PARADISE SENIOR HOME	FACILITY NUMBER: 195850356
	VISIT DATE: 09/06/2023

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Bedrooms # 3 and 4 need chests of drawers, All beds need to be 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’ - is required. All rooms were free of odors. All window screens were clean and maintained in good repair.

BATHROOMS: There is one (1) bathroom in the hallway, which has a bathtub. There is one private bathroom for bedroom #2, shower only. The residents’ bathrooms have non-skid mats. The toilet and shower have grab bars. Hot water temperature was tested in the bathroom(s) #1 and 2 it read 127.1 and the kitchen and was found to be within the range of 126.1 degrees Fahrenheit.

COMMON AREAS: 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. The dining room sliding door needs to be flushed with outdoor ramp at the level where wheelchairs and walkers may enter and exit the facility safely.
One outdoor ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. There is a fireplace (which is not real) in the living room. 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.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PARADISE SENIOR HOME	FACILITY NUMBER: 195850356
	VISIT DATE: 09/06/2023

NARRATIVE

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The laundry area is located in the garage. The supply of extra bed and bath linens is adequate, and is located in the linen closet found in the hallway between the garage and the bedrooms. Personal hygiene items (shampoos, soaps) were adequate and are stored incontinence closet. Extra incontinence supplies are stored in the incontinence closet.
The facility smoke alarm system is hard wired. The smoke detectors were tested and functioned properly during the time of visit. The facility needs a carbon monoxide detector. There is one (1) fire extinguisher mounted on the wall between the kitchen and the bedrooms. It was purchased on 09/01/2023, and it fully charged.
There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted on the wall between the kitchen and the bedrooms. The emergency telephone numbers will be relocated and will be posted next to the emergency exiting plans/sketch, on the wall between the kitchen and the bedrooms. Other required postings are posted in the living room area.

OUTDOOR AREA: The exterior passageways were clean and clear of any obstructions. There is a covered patio area at the back of the house with a table and chairs where residents can sit. A shaded area with an awning was available for residents. The entire property is 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 mechanically. There is a gate with a self-latching mechanism for persons to enter the front yard. There are no other structures on the property. There are no bodies of water on the premises at the present time.

The garage is accessible from the house; the doors were locked.
Resident and staff records are stored in a filing cabinet, which is currently located in the living room area. Medications are centrally stored in a locked cabinet in the kitchen. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. They are stored in a top kitchen cabinet.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PARADISE SENIOR HOME	FACILITY NUMBER: 195850356
	VISIT DATE: 09/06/2023

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The following items must be corrected prior to licensure. Submit proof of correction to the LPA by 09/12/2023 to reschedule a follow-up visit, so that your application may be completed.

1. Bedroom #1 needs one (1) bed, and linens.
2. Bedroom #2 needs two (2) beds, and linens, and one chest drawers.
3. Bedroom # 3 needs one (1) bed, and both beds need linens, and one chest drawers.
4. Bedroom # 4 needs linens on the bed.
5. Carbon Monoxide alarm needs to be purchased and placed on the wall.
6. Sliding doors in bedroom #1 and dining room leading to the backyard require an adaptor to make the floor level and to make passage from bedroom and dining room area to outdoors at the level where wheelchairs and walkers may enter and exit the facility safely.
7. Outdoor ramp from dining room needs to be reposition to make it flushed to the sliding door.
8. Water temperatures for the kitchen and bathrooms #1 and #2 need to between 105 to 120 degrees Fahrenheit.

At 1:30 p.m., the applicant completed Component III orientation.

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.

Exit interview was conducted and reviewed with applicant Knarik Davtyan. A copy of the report was issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

LIC809 (FAS) - (06/04)

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