197607871-12-9-2023-31-AS-AALR-CYCSDD-20231209124659

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607871
Report Date: 12/09/2023
Date Signed: 12/09/2023 12:47:06 PM

Document Has Been Signed on 12/09/2023 12:47 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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	A BURBANK RESIDENTIAL CARE		FACILITY NUMBER:	197607871
ADMINISTRATOR:	GAYANE DZHAGARYAN		FACILITY TYPE:	740
ADDRESS:	2020 SCOTT ROAD		TELEPHONE:	(818) 588-3916
CITY:	BURBANK	STATE: CA	ZIP CODE:	91504
CAPACITY:	6	CENSUS: 4	DATE:	12/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	07:30 AM
MET WITH:	Administrator, Levon Chalabyan		TIME COMPLETED:	01:00 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) Antonia Alvizar conducted an Annual Required visit and inspection of the facility. LPA met with Staff, Roza Proshyan then later Administrator, Levon Chalabyan joined us and explained the reason for the visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools. At 8:30 am, with the assistance of Administrator, Chalabyan LPA took a tour of the physical plant. Required postings & readily available for review were observed in the entrance and dining area. Smoke alarms and carbon monoxide detectors are interconnected also tested and function properly. There are two (2) Fire Extinguisher in the facility. One is near the kitchen and another is in the hallway and they are all fully charged. Fire extinguisher purchased dated 06/07/2023. The last fire drill was conducted on 11/03/2023. The following was observed: Structure: The facility is a single story house with four (4) resident bedrooms, two (2) full bathrooms, one (1) half bathroom, two (2) staff rooms, kitchen, living room, dining area, laundry room, back yard for shade with table and chairs and a detached garage. There's no bodies of water on the premises. All outdoor and indoor passageways are free of obstruction. Kitchen: The kitchen appliances and fixtures were functional. Knives, cutlery and other sharp kitchen utensils are stored and locked in the kitchen cabinet. Bedrooms Residents: There were four (4) bedrooms designated for clients' use. All bedrooms in use by residents were properly furnished with appropriate beddings and linens with sufficient lighting. Hygiene for each resident observed, ample supply of clean linen and storage space. Two (2) bedrooms are in use by staff. Bathrooms: There are two (2) full bathrooms and one (1) half bathroom designated for staff and residents. All bathrooms were properly supplied and had functional fixtures. Hot water temperature was tested between 113 to 115 degrees Fahrenheit.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2023

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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: A BURBANK RESIDENTIAL CARE	FACILITY NUMBER: 197607871
	VISIT DATE: 12/09/2023

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Food Service: LPA found a sufficient amount of 2 days perishable and 7 days non-perishable food at the facility properly stored. There are three refrigerators in the home, one in the kitchen and two in the garage for additional food storage. Dishes, cups and flat ware are stored in the kitchen cabinet, inspected and in good repair.
Toxins: All the cleaning solutions are locked and stored in the laundry room and garage.
Medications, First-Aid Kit & Book: Properly labeled medications and centrally stored and locked in a hallway cabinet and is only available for staff to use but inaccessible to clients. LPA reviewed the first-aid kit and book, the first aid kit has all required supplies.
Common Areas: These included the living room and dining area. All furnishings are in good repair, lighting is good, walls, ceiling and floors are also in good repair.
Surrounding Grounds: Entry/exits were free of obstruction. The outdoor area was free of hazards. No bodies of water were observed at the facility. There was a shaded patio area with functioning furnisher.
Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.
Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.
Staff and some residents were also interviewed using the CARE Tools questionnaire.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit.

Exit Interview Conducted / A Copy of the Report provided to Administrator, Levon Chalabyan.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2023

LIC809 (FAS) - (06/04)

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