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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607871
Report Date: 03/16/2022
Date Signed: 03/16/2022 02:19:51 PM


Document Has Been Signed on 03/16/2022 02:19 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:A BURBANK RESIDENTIAL CAREFACILITY NUMBER:
197607871
ADMINISTRATOR:GAYANE DZHAGARYANFACILITY TYPE:
740
ADDRESS:2020 SCOTT ROADTELEPHONE:
(818) 588-3916
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY:6CENSUS: 4DATE:
03/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Administrator Levon ChalabyanTIME COMPLETED:
02:30 PM
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Licensing Program Analyst(LPA) Jewel Baptiste conducted an unannounced visit for the purpose of an annual required visit. LPA met with Co-Administrator Levon Chalabyan and explained the purpose of today's visit. Administrator Chalabyan assisted LPA with today's visit.

Facility is licensed to serve 6 over the age of 60. 6 of which is non-ambulatory and 1 can be bedridden. Hospice waiver approved for 1 resident. Facility is a one story house in a residential area. LPA made a complete tour of facility which included: 6 bedrooms, 2 1/2 bathrooms, living room, kitchen, dining room, laundry area, outdoor area, and garage. Administrator certificate #6008374740 expires 9/10/22.


The following was observed, reviewed, and inspected: Bedrooms #1-5 are designated for residents. Bedroom #6 is designated for staff. Each bedroom contained the required furniture and linens as mandated, ample supply of perishable and non-perishable food items, first aid kit reviewed, toxins and sharp objects were locked and inaccessible to clients, sufficient linen supply, license and required documents were posted in the office area, trash cans with tight fitting lids, all smoke detectors and carbon monoxide detectors were tested and operable, fire extinguisher(s) fully charged, front and back yard clean and free of debris. Water temperature measured between 117- 118.3 degrees F. Staff files were reviewed. Medication for 2 residents was reviewed. Staff files, and P & I funds were reviewed. The last disaster drill was conducted on 3/4/22 .

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided to administrator.

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022
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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