195850548-10-23-2024-29-AS-EMOY-DABPRR-20241023113311

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850548
Report Date: 10/23/2024
Date Signed: 10/23/2024 11:34:12 AM

Document Has Been Signed on 10/23/2024 11:34 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:	VITA LIVING		FACILITY NUMBER:	195850548
ADMINISTRATOR/ DIRECTOR:	NAZARYAN, DAVIT		FACILITY TYPE:	740
ADDRESS:	15434 LA MAIDA ST		TELEPHONE:	(818) 309-9939
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91403
CAPACITY: 6		CENSUS: 0	DATE:	10/23/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:40 AM
MET WITH:	DAVIT NAZARYAN		TIME VISIT/ INSPECTION COMPLETED:	11:45 AM

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) Erica Mosley conducted a pre-licensing visit to the above noted facility. The LPA met with applicant, Davit Nazaryan. This is a new facility. A dementia program was included in the plan of operation. A Hospice Waiver has been requested. The facility is single story house. At 9:40AM, a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for 4 non-ambulatory residents in rooms 2,3 and 4 ;1 ambulatory resident in room 1; and 1 bedridden resident in room 4. The facility has 2 private resident bedrooms, Rooms # 1 and 2 and 2 shared room(s), Room # 3 and 4. Room 4 has direct exits to the outside. All resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs, and closet space. The beds are 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. All rooms were free of odors. All window screens were clean and maintained in good repair. There are 3 bathrooms. 1 bathroom is designated as a staff bathroom. The resident bathroom(s) has a shower with non-skid materials. The toilet and shower have grab bars. Bedroom 4 has a private bathroom. The hot water temperature was tested in the bathrooms and the kitchen and was found to be within the range of 105F and 120F. Report continued on LIC 809C 2nd page...

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024

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: VITA LIVING	FACILITY NUMBER: 195850548
	VISIT DATE: 10/23/2024

NARRATIVE

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Continued from LIC 809 1st page...

Resident and staff records are stored in filing cabinet/ tv stand which is currently located in the living room area . Medications are centrally stored in a locked cabinet in the kitchen area and also have a locked mini refrigerator for medications that require refrigeration. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. They were stored in a the kitchen area where medications will be stored.
Kitchen knives are stored in a locked drawer in the kitchen. Stove burners are rendered inaccessible to the residents by removing them when not in use. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. 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 in a locked cabinet located in the laundry area. No flies or other vermin were observed.

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 nonprivate bathrooms. All 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 in the living room. It is screened and there are no tools. 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. 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.

Report continued on LIC 809C 3rd page...

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024

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: VITA LIVING	FACILITY NUMBER: 195850548
	VISIT DATE: 10/23/2024

NARRATIVE

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Continued from LIC 809 2nd Page...

The facility smoke alarm system is hard wired. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit.
There are 2 of fire extinguishers throughout the house. They are fully charged and do not exceed the expiration date.
Hot water was tested in each bathroom, which included the resident bathroom(s) and any common bathrooms, in addition to the kitchen; and, the hot water ranged from 105 to 120 degrees Fahrenheit. The laundry area is located in the hallway. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in the bathroom locked and in the garage. Extra incontinence supplies are stored in garage. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted at the entry way. The emergency telephone numbers are posted in the entry way. Other required postings are posted at the entry way.

The exterior passageways were clean and clear of any obstructions. There is a covered patio / court yard area at the center of the house with a table and chairs where residents can sit. 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. There are no other structures on the property. There is a small portable water structure in the court yard area.
The garage is accessible from the house; the doors were locked and will remain locked and inaccessible to residents in care.

No citations issued on a pre-licensing visit.

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.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024

LIC809 (FAS) - (06/04)

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