197608963-11-27-2023-31-AS-AALR-CXYW5H-20231127155911

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608963
Report Date: 11/27/2023
Date Signed: 11/27/2023 03:59:20 PM

Document Has Been Signed on 11/27/2023 03:59 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:	HAMPTON VILLA		FACILITY NUMBER:	197608963
ADMINISTRATOR:	MICHAEL PETROSIAN		FACILITY TYPE:	740
ADDRESS:	706 HAMPTON ROAD		TELEPHONE:	(818) 433-7266
CITY:	BURBANK	STATE: CA	ZIP CODE:	91504
CAPACITY:	6	CENSUS: 6	DATE:	11/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:			TIME COMPLETED:	04:00 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 unannounced Annual Required visit to this facility. LPA met with Administrator, Michael Petrosian and explained the reason for the visit. At 11:00a.m. LPA and Administrator tour of the physical plant for compliance with safety, maintenance, and operational requirements. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Facility is a single-story house in a residential neighborhood and consisting of a common area, three (3) bedrooms, one (1) full bathroom and a half (1/2) restroom currently occupying six (6) residents. There is one entrance being utilized at the facility, there are required posters at the main door. Smoke detectors are hard wired and are interconnected. Smoke detectors and Carbon Monoxide detectors were tested and function properly. Facility disaster drills was conducted on 11/01/2023. The facility maintains a comfortable temperature at 74°F. There is a charged fire extinguisher in the facility. Fire extinguisher is located in the laundry room. Fire extinguisher is fully charged and receipt of purchased was 01/09/2023. Cleaning supplies and toxic substances are inaccessible to residents. Hot water temperature was tested in common bathroom and in the kitchen. The hot water temperatures measured between 107.2 - 110.1 degrees Fahrenheit (F) which are within the required range for residents comfort and safety. Kitchen: The kitchen appeared clean and fixtures functional. Kitchen knives and other sharp items are stored in a lock drawer in the kitchen. The supply of dishes and eating utensils was more than adequate. Household cleaning and supplies are kept locked in a cabinet under the sink. On the premises that is in the kitchen there was a functional telephone. Laundry Room: Equipped with washer and dryer. Laundry supplies are kept locked in a cabinet. Located next to the kitchen.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

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: HAMPTON VILLA	FACILITY NUMBER: 197608963
	VISIT DATE: 11/27/2023

NARRATIVE

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Continued from 809)
Bedrooms: The residents’ bedrooms were properly furnished and had adequate lighting and closet space. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets.

Bathrooms: LPA observed all bathrooms to be clean, properly supplied and had functional fixtures. LPA observed grab bars in both bathrooms. The full bathroom had non-skid mat in shower. Residents have enough personal hygiene supplies.

Common Areas: The living room has a television, a couch and two (2) recliner chairs. The common areas were checked for cleanliness and furniture was checked for functionality. All areas were clean, sanitary and in good repair. At 2:46p.m. LPA observed residents having snack. At 3:15pm LPA observed residents having coloring in the dining table.

Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use in the back of the facility. There are no bodies of water and firearms on the premises.

Garage: Detached located in the rear of the facility, which stores personal protected equipment (PPE), emergency food, maintenance supplies, two (2) operation refrigerators with extra Non-perishable and perishable food.

In addition to the physical plant LPA conducted a file review for all residents and staff regularly scheduled. Staff have current first aid and training documentation showing required training completed. Resident records observed to be complete at this time.

Per California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, deficiencies were not observed/cited. Exit interview conducted and copy of report provided to Administrator.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

LIC809 (FAS) - (06/04)

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