197608585-6-10-2023-31-AS-EDAT-CSNVQ7-20230610163751

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608585
Report Date: 06/10/2023
Date Signed: 06/10/2023 04:38:34 PM

Document Has Been Signed on 06/10/2023 04:38 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
Lookup Error,
, CA

FACILITY NAME:	BUENA VISTA VILLA RCFE		FACILITY NUMBER:	197608585
ADMINISTRATOR:	GAYANE DZHAGARYAN		FACILITY TYPE:	740
ADDRESS:	2741 N. BUENA VISTA STREET		TELEPHONE:	(818) 478-1357
CITY:	BURBANK	STATE: CA	ZIP CODE:	91504
CAPACITY:	6	CENSUS: 5	DATE:	06/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:33 AM
MET WITH:	Harut Sargsian		TIME COMPLETED:	11:34 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	On 06/10/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with house manager Harut Sargsian. LPA explained the purpose of today’s visit. Gayane Dzhagaryan the administrator was unavailable to be present for the visit. The facility is licensed to operate for (6) non-ambulatory elderly adults ages 60 and above. Currently, the facility has no hospice residents in care. The facility is approved for (3) hospice residents. The residents are all Laterman Regional Center residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: (3) residents' rooms, (2) bathrooms, a living area, a dining area, a kitchen, an outside seating area, and a garage. LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 105.0 degrees F. A comfortable temperature of 70 degrees F was maintained in the facility. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to clients. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. A fire extinguisher was charged. A review of the Medication Records Administration (MAR) was observed to be maintained in place. (Evaluation Report continues on LIC 809-C)

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) -98-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2023

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
Lookup Error,
, CA

FACILITY NAME: BUENA VISTA VILLA RCFE	FACILITY NUMBER: 197608585
	VISIT DATE: 06/10/2023

NARRATIVE

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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on 04/01/23 and the earthquake drill on 05/01/23. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective 06/09/23 - 06/09/24.

An audit of resident #1-#5 (R1-R5) service files and staff #1-#3 (S1-S3) personnel files was revealed to be complete. An audit of the resident's P&I is maintained in order and complete. Interviews were conducted with (3) residents and (1) staff. The facility has the current administrator's certification on file for Gayane Dzhagaryan expiration date 09/10/24 #6018203740

No deficiencies during this inspection visit.

An exit interview was conducted with Harut Sargsian and a copy of the report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) -98-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2023

LIC809 (FAS) - (06/04)

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