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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850360
Report Date: 08/28/2023
Date Signed: 08/28/2023 04:00:30 PM

Document Has Been Signed on 08/28/2023 04:00 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:AY SENIOR CARE INCFACILITY NUMBER:
195850360
ADMINISTRATOR:MKRTCHYAN, ARPINEFACILITY TYPE:
740
ADDRESS:6623 VESPER AVETELEPHONE:
(818) 404-0550
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY: 6CENSUS: 0DATE:
08/28/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Arpine Mkrtchyan, ApplicantTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Christine Yee conducted an announced Prelicensing and Component III visit using the CARE Inspection Tool. LPA Yee conducted the visit with Arpine Mkrtchyan, Applicant and Arsen Yanukyan, Staff.

The facility is a single storey family home consisting of a living room, a dining room, a kitchen, 4 resident bedrooms and 2 full bathrooms. The facility is fire cleared for 5 NON-AMBULATORY and 1 BEDRIDDEN residents. Bedroom #4 is the bedroom designated for bedridden use.

The following were observed on today's visit:
  • The living room and dining room are furnished with the appropriate furnishing and seating for 6 residents.
  • The kitchen has a stove, dishwasher and refrigerator. Sufficient plates, cups, utensils for 6 residents were observed. Pots, pans, storage containers were observed. Perishable foods for a minimum of 2 days will be purchased prior to accepting the first resident and additional non-perishable for a minimum of 7 days will be purchased and maintained on the premises.
  • Located in the kitchen is the only fire extinguisher that was purchased on 3/22/23.
  • Employment Poster was posted in the dining room and the required posting were observed in the living room.
  • Bedroom #1, directly by the front door, was observed with 2 hospital bed, 2 night stands, 2 lamps, 2 folding chairs and a shared closet. Plastic rolling drawers were purchased but did not meet Title 22 requirements. Beds did not have any bed covers.
  • Bedroom #2 is a private room and contains 1 hospital bed, 1 folding chair, 1 night stand, 1 lamp and and a plastic rolling drawer that does not meet Title 22 requirements and no bed covers.


LIC809-C
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: AY SENIOR CARE INC
FACILITY NUMBER: 195850360
VISIT DATE: 08/28/2023
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  • Bedroom #3, located at the back of the home was observed with 2 hospital bed, 2 night stands, 2 lamps, 2 folding chairs and a shared closet. Plastic rolling drawers were purchased but did not meet Title 22 requirements. Beds did not have any bed covers.
  • Located inside Bedroom #3 is a private bathroom equipped with a bath tub, a toilet, a 2 sink vanity. Grab bars and non-skid mat was observed. Water temperature was tested and read 114.1 degrees Fahrenheit.
  • Bedroom #4, located at the back of home, is the designated bedridden room. The room was observed with a hospital bed, a night stand, a lamp, a folding chair, a closet. The sliding glass door opens directly on to a ramp with a railing.
  • Blinds were observed on all the bedroom windows. No window bars were observed.
  • The common bathroom located between bedroom #1 and bedroom #2 was equipped with a shower stall, a sink and a toilet. Grab bars and non-skid mats were observed. Water temperature was tested and it read 114.4 degrees Fahrenheit.
  • 12 bath towels, 12 hand towel and 12 face towels were observed in the linen closet. Extra set of bed linen and blanket were so observed.
  • Hygiene products were observed stored in the laundry room. Toilet paper, paper towels and water were observed in the closet by the front door.
  • First aid kit and first aid manual was observed/
  • Night lights were observed in resident bedrooms and in the hall way.
  • Auditory devices were installed on the front door, kitchen door and the sliding glass door in bedroom #4
  • A carbon monoxide detector was observed installed above the door of bedroom #4
  • The hardwired smoke and carbon monoxide combination detectors were tested at 2:03pm and were operational.
  • The facility has a land line telephone. The facility telephone number is (818)387-8161
  • The backyard was observed with a large gazebo. A table with 4 chairs and a bench was observed. Backyard was clean. No bodies of water were observed.
  • The front yard was observed with a cover patio and furnished with a cafe table and 2 chairs.
  • Trash cans were observed tightly sealed.



Continued on LC809-C
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: AY SENIOR CARE INC
FACILITY NUMBER: 195850360
VISIT DATE: 08/28/2023
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The following corrections need to be completed prior to licensure:
  • dressers meeting Title 22 requirements need to be purchased for all 4 residents bedrooms
  • comforters / bed covers need to be purchased for all resident beds.


Licensee will provide evidence that dressers and comforter were purchased.

The following needs to be in place prior to accepting the first resident:

  • purchase perishable foods for a minimum of 2 days and supplement non-perishable foods for 7 days prior to accepting the first resident
  • ensure that liability insurance is purchased meeting Title 22 requirements - 1 million per incident for total aggregate of 3 million dollars, upon licensure.



Component III was conducted with Arpine Mkrtchya, Applicant, on today's visit..


Exit interview was conducted
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3