195850391-10-31-2023-29-AS-CYEE-CX5VMY-20231031163418

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850391
Report Date: 10/31/2023
Date Signed: 10/31/2023 04:34:24 PM

Document Has Been Signed on 10/31/2023 04:34 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	VAN NUYS SENIOR LIVING, INC.		FACILITY NUMBER:	195850391
ADMINISTRATOR:	AYVAZYAN, SARGIS		FACILITY TYPE:	740
ADDRESS:	14822 COHASSET STREET		TELEPHONE:	(747) 253-0007
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY:	6	CENSUS: 0	DATE:	10/31/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Sargis Ayvazyan, Applicant		TIME COMPLETED:	04:40 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 Pre-licensing and Component III visit and met with Sargis Ayvazyan, Applicant and Marine Danielyan, Spouse/Staff. The facility is a single storey family home consisting of a living room, dining room, kitchen, 4 bedrooms of which one is used for live-in staff, a office, a laundry room, 2 full bathrooms and a attached garage. The facility is fire cleared for 3 NON-AMBULATORY and 3 BEDRIDDEN residents. Bedrooms #1, #2 and #4 are designated for bedridden residents. The home is also equipped with a sprinkler system. The following was observed on today's visit: the living room is furnished with a sofa and 2 armchairs. Located in the living room is a fire place. A fire screen was not observed. the dining room has a glass table with 6 chairs the kitchen is equipped with a stove, microwave and 3 refrigerator. Cleaning supplies are stored in a locked cabinet under the kitchen sink. Knives are stored in a locked kitchen drawer. 13 dinner plates, 3 salad plates, 9 bowls, 4 cups, 3 plastic glasses, pots, pans, 6 dinner forks, 6 desert forks, 6 dinner knives, 6 tablespoons and 6 teaspoons were observed. No perishable foods were purchased and additional non-perishable foods for 7days were purchase during the visit. The only fire extinguisher, purchased on 7/17/23 and the carbon monoxide detector are located in the kitchen. 2 first aid kits and a first aid manual were observed in the kitchen. Tweezers, scissors were observed but no thermometer adjacent to the kitchen is the laundry room with a washer and dryer. A linen closet with 18 bath towels, 18 hand towels and 18 face towel and extra fitted sheets were observed. the attached garage can be accessed through the laundry room. The garage needs to be cleaned out due to excessive items stored in the garage

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

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

FACILITY NAME: VAN NUYS SENIOR LIVING, INC.	FACILITY NUMBER: 195850391
	VISIT DATE: 10/31/2023

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

resident bedrooms #1, bedroom #2 and bedroom #4 all contain 2 twin beds, 2 night stands, 2 lamps, 1 shared dresser and a built in closet, except bedroom #4 has 2 walk in closets. No chairs were observed. The 3 rooms have doors that lead directly to the outside and were equipped with auditory
devices. Ramps were also observed. Window dressings for privacy were observed.
bedroom #3 will be used for a live-in staff and was not furnished.
the two common bathrooms, one located in the front and one located in the back, are equipped with a open shower, a toilet and a sink. Grab bars were observed. The bathrooms did not have any non-skid mats. A shower chair was observed in the front bathroom. Water temperature was tested and the water in the back bathroom read 123.3 degrees Fahrenheit and the front bathroom read 121.8 degrees Fahrenheit. Thermostat was adjusted during the visit and retested at 4:15pm and it read 105 degrees Fahrenheit
Medications will be centrally stored in a locked hallway closet
the required posters were observed by the front door
all exit doors to the outside are equipped with auditory devices
resident and staff files will be stored in the office.
3 shampoo and 8 rolls of toilet paper were observed. Other hygiene products such as bath soap, toothpaste, toothbrushes, combs need to be purchased.
the hardwired smoke detectors located in the resident rooms and hallway were tested and were operational
cameras were observed in the common areas and in bedroom #3. Per applicant, the cameras are not operational and may be replaced. Applicant was advised to either remove or submit a written addendum to update the facility's plan of operation to indicate where the cameras are installed and how the information will be used and who has access to the information.
6 chairs were observed set up in the front of the facility
the front yard, backyard and the sides of house need to be cleaned out and unused/discarded items and furniture need to be thrown out or stored away. The weeds and grass need to be removed/mowed. The hedge needs to be trimmed.
the facility has a land line. Telephone # is (747) 225-2070
Applicant will obtain liability insurance in the required limits once the facility is licensed.

The following corrections need to be addressed prior to licensure or as noted:

a fire screen needs to be placed in front of the fire place
a thermometer needs to be purchased for the first aid kit

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

LIC809 (FAS) - (06/04)

Page: 3 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VAN NUYS SENIOR LIVING, INC.	FACILITY NUMBER: 195850391
	VISIT DATE: 10/31/2023

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

cups and glasses need to be purchased for 6 residents
flat sheets, blankets and pillow cases needs to be provided and extra bed linens need to be purchased to allow for changing weekly and as needed.
the garage needs to be cleaned out and all excess items due to construction need to be removed
chairs for each resident need to be provided in all the resident bedrooms
non-skid mats need to be provided in the bathrooms
hygiene products and additional toilet paper need to be purchased
perishable foods need to be purchased prior to the acceptance of the first resident.
Liability insurance meeting Title 22 requirements will be purchased upon licensure
the backyard, front yard and sides of the house need to be cleaned and items stored or discarded.
a table for activities, chairs and an umbrellas provided for outside activity

Applicant will provide evidence of the above corrections once it has been completed.

COMPONENT III was conducted on today's visit with Sargis Ayvazyan and Marine Danielyan

Exit interview was conducted.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3