197608585-5-19-2024-31-AS-JGTN-D5EUL7-20240519154015

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608585
Report Date: 05/19/2024
Date Signed: 05/19/2024 03:40:53 PM

Document Has Been Signed on 05/19/2024 03:40 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:	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:	05/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:23 PM
MET WITH:	MIchael Petrosyan - Co Administrator		TIME COMPLETED:	03:45 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) Gary Tan, met with Administrator Michael Petrosyan for a one (1) year required visit for this facility. Purpose of the visit was stated. This is a Lanterman Regional Center vendored facility level 4D. There is only one entrance being utilized at the facility, there are required poster posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation and Infection Plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. A tour of the physical plant was conducted with the Administrator at 12:45 PM. The facility has three (3) bedrooms and two (2) bathrooms currently occupying five (5) residents. The facility is fire cleared for six (6) non-ambulatory residents. Hospice waiver for three (3) residents. Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, the following was noted: Living and dining room furniture were also checked. The living room is neat and clean along with the dining room. The facility maintains a comfortable temperature at 72°F. Dual smoke/carbon monoxide detector is hardwired and interconnected, tested and observed to be operational. There is a fire extinguisher in the facility located in the kitchen. Fire extinguisher was observed to be full and last inspected on 02/06/24. (continued on LIC 809-C)

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2024

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

FACILITY NAME: BUENA VISTA VILLA RCFE	FACILITY NUMBER: 197608585
	VISIT DATE: 05/19/2024

NARRATIVE

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The backyard of the facility has outdoor furniture, with a covered shaded area for clients. There is no body of water in the facility. The garage is detached to the home. It is currently being used as storage for PPE, frozen foods, tools and old equipment. It is also being used as a Laundry area. The garage is observed to be locked and inaccessible to residents. Laundry detergents, cleaning solutions and other chemicals and toxins are locked and secured in the cabinet in the garage.

Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Dishwashing liquids and other cleaning supplies were stored in the locked in garage. All sharps and knives were also observed to be locked in a kitchen drawer.

The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit to non-private rooms. Clients have sufficient amounts of personal hygiene product which is provided by the licensee. The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. The hot water temperature measured at 107.7°F to 112.6°F. Towels and washcloths are not shared. There is enough clean linen available in stock at the cabinet.

Medications: LPA observed medication were kept in the medication cabinet along the bedroom hallway and observed to be locked and inaccessible to residents. Medications are listed on the centrally stored medication and destruction record. There is a complete first aid kit located in the bedroom hallway.
Client records: Client records are reviewed and appeared to be complete and updated. Staff records: LPA also conducted a complete file review of staff records. Staff record appeared to be complete and updated.

Disaster drill was last conducted on 05/01/24. Required posting are observed to be complete and current and displayed properly at the facility.

Exit interview conducted and copy of this report issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2024

LIC809 (FAS) - (06/04)

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