197609357-12-19-2023-31-AS-AALR-CYNU9V-20231219142347

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609357
Report Date: 12/19/2023
Date Signed: 12/19/2023 02:23:56 PM

Document Has Been Signed on 12/19/2023 02:23 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:	BIRMINGHAM VILLA		FACILITY NUMBER:	197609357
ADMINISTRATOR:	LEKHLYAN, ANAHIT		FACILITY TYPE:	740
ADDRESS:	825 BIRMINGHAM RD		TELEPHONE:	(818) 859-7777
CITY:	BURBANK	STATE: CA	ZIP CODE:	91504
CAPACITY:	6	CENSUS: 6	DATE:	12/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Administrator Christine Lekhlyan		TIME COMPLETED:	02:45 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) Antonia Alvizar conducted an Annual Required visit and inspection of the facility. Upon arrival, LPA met staff Susanna Hayrapetyan who assisted with the visit. Shortly after Administrator Christine Lekhlyan arrived. The purpose of the visit was explained. The facility is licensed to serve 6 (six) non-ambulatory residents. Hospice Waiver for (3) three residents. Residents receive services from the Frank D. Lanterman Regional Center. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools. At 9:25 am, with the assistance of Administrator, Lekhlyan and LPA toured the physical plant area inside and outside to ensure there are no health and safety hazards. Required postings and readily available for review were observed in the office area. Smoke alarms and carbon monoxide detectors are interconnected also tested and function properly. There was a fire extinguisher observed to be fully charged in the dining area. The last fire drill was conducted on 12/06/2023. The following was observed: Structure: The facility is a single story house with six (6) bedrooms, one (1) Staff room, two (2) full bathrooms, one (1) half bathroom, kitchen, living room, dining room, laundry machines in office space area, side yard for shade with table and chairs. 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 six (6) 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. One (1) bedroom is 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 with required grab bars and non-skid mats and functional fixtures. Hot water temperature was tested between 110 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: 12/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

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: BIRMINGHAM VILLA	FACILITY NUMBER: 197609357
	VISIT DATE: 12/19/2023

NARRATIVE

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Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in resident bedrooms and hallway closet.
Food Service: LPA found a sufficient amount of 2 days perishable and 7 days non-perishable food at the facility properly stored. There is one (1) full size refrigerator in the kitchen, two (2) small refrigerators, one (1) freezer in the dinning area and additional food storage in the office area. 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 hallway closet.
Medication and First-Aid Kit: Properly labeled medications and centrally stored and locked in a kitchen cabinet and is only available for staff to use but inaccessible to clients. LPA reviewed the first-aid kit, it had 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.
Medications: Medication and Medication Records were review for proper documentation. They are locked and stored in a kitchen cabinet.

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, Lekhlyan.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

LIC809 (FAS) - (06/04)

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