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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850523
Report Date: 12/17/2024
Date Signed: 12/17/2024 04:05:55 PM

Document Has Been Signed on 12/17/2024 04:05 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:PACIFIC SENIOR CAREFACILITY NUMBER:
195850523
ADMINISTRATOR/
DIRECTOR:		HAYRAPETYAN, VIKTORYAFACILITY TYPE:
740
ADDRESS:7731 ALDEA AVETELEPHONE:
(818) 516-8819
CITY:LAKE BALBOASTATE: CAZIP CODE:
91406
CAPACITY: 6CENSUS: 0DATE:
12/17/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Viktorya HayrapetyanTIME VISIT/
INSPECTION COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Sandra Urena conducted a Pre-licensing visit and met with the applicant Viktorya Hayrapetyan. This is a new facility application for a Residential Facility for the Elderly (RCFE ) for six (6) non-ambulatory residents, no bedridden residents can be admitted. Fire Clearance was approved on 05/13/2024 for all rooms for non-ambulatory use.

At 11:15 a.m., the LPA, and the applicant toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen knives are stored locked and inaccessible in a locked kitchen drawer. A seven-day supply of non-perishable food was available. The supply of dishes is adequate. Appliances in the kitchen were clean and all appeared functional. Kitchen cleaning supplies will be stored and locked under the kitchen sink. Hot water temperature was recorded at 118.1 degrees Fahrenheit. Trash cans have a tight-fitting lid. There were no pesticides or toxins stored near food, or preparation area. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. A fire extinguisher is located near the backdoor exit, which was purchased on 04/19/2024.

BEDROOMS: There are three (3) bedrooms for residents in care. Rooms 1, 2 and 3 will be a shared rooms; all bedrooms are cleared for non-ambulatory. All bedrooms were supplied with all required bedding and linens. There is sufficient lighting as well as closet and drawer space available. Bedrooms (1 and 2) closets will have a divider installed to separate residents clothing. Bedroom 3 closet will be cleared of items (wheelchairs, walkers, storage items, etc.)


BATHROOMS: There are (2) full bathrooms, with shower and bathtubs, and one (1) restroom. Bathrooms are equipped with toilets and shower grab bars, and non-skid mats. There are sufficient supplies of towels, paper goods and personal hygiene supplies. Hot water delivered was between 117.6 to 119.1 degrees Fahrenheit. Continues on LIC 809C...
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
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: PACIFIC SENIOR CARE
FACILITY NUMBER: 195850523
VISIT DATE: 12/17/2024
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COMMON AREAS: These include a living room area equipped with a television. The fireplace is non-functional and has a fireplace screen. There is a dedicated area for the posting of required documents at the entrance of the facility. Smoke and carbon monoxide alarms were tested and functional at the time of the visit. Medications will be stored in a locked cabinet in the kitchen area. The residents’ and staff files will be stored and locked in a closet area located in the foyer.

LAUNDRY ROOM: There is a laundry area equipped with washer and dryer. The laundry room is located in the hallway between the restroom and bedroom 1. Detergents and cleaning supplies will be stored in locked cabinet above the washer and dryer.

SURROUNDING GROUNDS: The exterior passageways were clean. Some items such as buckets and other outdoor items will be removed. The patio is furnished with outdoor furniture for residents’ use, and shade is available. The building has a central entrance for residents and visitors. Left passageway is cleared and has a self-latching gate. The self-latching mechanism is located on the outside of the gate facing the street.
At the time of the visit the LPA observed two ADU units. One unit is identified by the address #7731-1/2 and is located on the right-hand side of the facility; one person lives in this ADU. The second ADU is identified by the address #7733 and is located behind the facility and is divided by growing shrubs and a wooden gate; two people live in this ADU. Applicant stated that all persons living in the two ADU units have been background cleared and associated to the facility. LPA Urena will verify the clearances and association to the facility upon returning to the Regional Office.

Continues on LIC 809C...
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
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: PACIFIC SENIOR CARE
FACILITY NUMBER: 195850523
VISIT DATE: 12/17/2024
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Pre-Licensing is incomplete with deficiencies to be resolved by Friday, 12/20/2024. Follow up Pre-licensure LIC809 will be generated upon resolution.

· The Licensing Complaint poster will be moved to a more prominent area.

· Linen closet will be installed to keep all linens and towels stored.

· Bedrooms (1 and 2) closets will have a divider installed to separate residents clothing.

· Bedroom 3 closet will be cleared of items (wheelchairs, walkers, storage items, etc.)

· Applicant will inform CAB of the new facility telephone number.

· Applicant will obtain Emergency lighting supplies (flashlights, batteries) and keep at facility.


At 01:32 p.m. the applicant completed Component III orientation.

This report will be sent to the Centralized Application Bureau (CAB). 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 the applicant. A copy of the report was issued.


SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC809 (FAS) - (06/04)
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