195850401-12-15-2023-29-AS-CYEE-CYK45S-20231215174826

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850401
Report Date: 12/15/2023
Date Signed: 12/15/2023 05:48:33 PM

Document Has Been Signed on 12/15/2023 05:48 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:	PRESTIGE RESIDENTIAL CARE FACILITY		FACILITY NUMBER:	195850401
ADMINISTRATOR:	SADOYAN, NELLI		FACILITY TYPE:	740
ADDRESS:	6019 WILLOWCREST AVE		TELEPHONE:	(818) 429-9809
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY:	6	CENSUS: 0	DATE:	12/15/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:06 AM
MET WITH:	Nelli Sadoyan, Applicant		TIME COMPLETED:	05:55 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 a pre-scheduled Prelicensing and Component III visit and met with Nelli Sadoyan, Applicant and Hrant Narinyan, Designated House Manager. The facility is a single storey family home consisting of a living room, dining room, kitchen, 3 resident bedrooms, an office, 2.5 bathrooms and a detached garage. The facility fire clearance is currently in the process of being corrected. The following were observed on today's visit: The living room is furnished with 2 sofa, an arm chair, a television and a coffee table The dining room is furnished with a table 5 chairs and the 6th chair was observed in the office. The kitchen is equipped with a dishwasher, oven, stove and microwave. Non-perishable food for a minimum of 7days were reviewed and needs to be supplemented. Perishable foods will be purchased prior to accepting the first resident. Bedroom #1 is furnished with 1 bed, 1 chair, 1 night stand, 1 lamp, a dresser and a built in closet. Curtains need to be thicker to allow for privacy Bedroom #2 is furnished with 2 beds, 2 chairs, 2 night stands, 2 dressers and only 1 portable closet. The room has a French door that opens out to a ramp. Auditory device on the door was operational. The window curtain was observed to be thin gauze and needs to be thicker to afford privacy. Located inside the bedroom is a full bathroom with a toilet, a sink, a shower, grab bars, a shower chair and a non-skid mat. Water temperature was tested and read 117.5 degrees Fahrenheit. Bedroom #2 is designated for a bedridden resident. Bedroom #3 is furnished with 2 beds, 2 chairs, 2 night stands, 2 dressers, a closet and a cupboard. Curtains need to replaced with thicker ones to afford privacy to the residents.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

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: PRESTIGE RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 195850401
	VISIT DATE: 12/15/2023

NARRATIVE

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The common bathroom located by bedroom #1 is equipped with a bath tub/shower, a sink, a toilet and non-skid mat. The shower did not have a grab bar. Water temperature was tested and read 109.5 degrees Fahrenheit.
The shower room located behind the kitchen is equipped with just a shower stall. Grab bars, non-skid mat and a shower chair was observed.
First aid kit was reviewed and contained just a tweezer. Scissors and thermometer was not observed.
No first aid manual was observed.
The only fire extinguisher purchased on 9/12/23 is located in the dining room
The facility's land line number is (818)308-6030
Toxins/cleaning solutions are stored in locked cabinets in the common bathroom
Dish washing solutions are stored in a locked cabinet under the kitchen sink
Medications will be stored in a locked kitchen cupboard.
Knives are stored in a locked kitchen drawer
There were 12 each of forks, dinner knives, teaspoons, tablespoons, dinner plates, salad plates and bowls, 12 glasses and 12 cups. Pots and pans were observed.
Mattress pad, fitted sheets, flat sheets, pillows and comforters were observed on the beds. Blankets were observed in bedroom #2 and 1 in bedroom #3. A blanket was missing in bedroom #1 and 1 in bedroom #3. Extra flat sheets, fitted sheets and pillow cases were in the linen closet. 6 bath towels were observed and plenty handle towels and face towels were observed.
Applicant will obtain liability insurance once the facility is licensed for the required limits.
Hygiene products were observed.
A table and chairs for outside activities were observed in the front yard.
The backyard, and the left side of the house needs cleaning and items stored in the outside areas need to be discarded or stored away and the tall grass mowed.
No bodies of water was observed.

The following corrections need to be made prior to licensure:

A corrected fire clearance needs to be obtained from the fire department
A revised LIC200 needs to be submitted to the Centralized Application Bureau to reduce the capacity from 6 to 5 residents since the room currently designated as the office does not qualify as a bedroom.
A blanket need to be provided in Bedroom #1 and bedroom #3.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

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: PRESTIGE RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 195850401
	VISIT DATE: 12/15/2023

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Additional blankets and towels need to be purchased
An additional portable closet needs to be purchased for Bedroom #2
A grab bar needs to be installed in the common bathroom tub/shower
Non-perishable foods need to be supplemented.
a pair of scissors and a thermometer needs to be purchased for the first aid kit
a first aid manual that meets Title 22 needs to be purchased
The window dressings in the bedrooms need to be replaced with coverings/curtain that provide privacy to the resident.
The latch that is installed on the outside of left side gate needs to be removed and replaced with some other method of securing the gate to allow residents to exit freely.

Applicant will notify LPA Yee once the corrections have been completed and to schedule a return visit. Anything overlooked on this visit will be addressed on the return visit.

Exit interview was conducted with Nelli Sadoyan

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

LIC809 (FAS) - (06/04)

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