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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609624
Report Date: 10/29/2021
Date Signed: 10/29/2021 12:01:58 PM

Document Has Been Signed on 10/29/2021 12:01 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:MAGIC VILLA INCFACILITY NUMBER:
197609624
ADMINISTRATOR:DOMIO, ANAITFACILITY TYPE:
735
ADDRESS:8526 CRANFORD AVETELEPHONE:
(747) 998-3399
CITY:SUN VALLEYSTATE: CAZIP CODE:
91352
CAPACITY: 4CENSUS: 1DATE:
10/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Narek Davtyan & Jovinah BuleziTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Tuesday Cabiness arrived at the facility to conduct an unannounced infection control inspection/visit. Upon entry, LPA was greeted by staff Jovinah Bulezi, who allowed LPA to enter. There have not been any active or past COVID cases at the facility, and (2) staff and (2) clients have been vaccinated. The current census is (2); one client was out in the community for the weekend. LPA’s temperature was immediately taken and documented; a list of COVID-19 questions was asked; and LPA signed in the visitor book. LPA observed staff to have full mask covering; a hand sanitizing station; PPE supplies in drawer; and COVID-19, CDC, Department of Public Health, and Licensing postings on the walls throughout the facility. The Administrator Narek Davtyan arrived shortly after, and LPA discussed the mitigation plan that was submitted and approved.

The infection control inspection began with the staff Jovinah and concluded with Administrator Narek. The facility has (3) bedrooms; with (1) shared room and beds were kept (6) feet apart. All bedrooms were properly furnished. The common areas were observed to be clean, including bathrooms, with soap and towels. LPA conducted a mitigation plan review with the Administrator, to obtain information on how the facility has implemented the plan. The Administrator reported to LPA, that (2) clients have been vaccinated and recently obtained the booster shot. Only (2) staff are vaccinated; the others conduct weekly testing and the facility keeps documentation of the test results and other pertinent information pertaining to COVID-19. All new employee hires and new resident admits, must be properly screened, and provide (2) negative COVID test, prior to entering the facility. Administration continues to conduct training to staff in relation to COVID-19. Administrator reported the facility receives departmental emails. There is currently no paid sick leave policy in place; but Administrators have had discussions regarding it, and will address when needed.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MAGIC VILLA INC
FACILITY NUMBER: 197609624
VISIT DATE: 10/29/2021
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There are designated rooms for potential positive COVID clients. PPE, chemicals, cleaning supplies, emergency food and water, personal hygiene supplies, and paper products are stored in a locked closet. LPA observed a sufficient supply of all items during the visit. LPA observed the facility has Licensing requirement for food supply. Currently, the facility has sufficient staff, and has back-up staff in place if needed. The facility has not had any positive COVID-19 reports for staff or clients. The Administrator informed LPA that they continue to implement the best practices for their facility, which has kept them COVID-19 free. The facility is aware to report any changes with clients and staff to Licensing and there LPA, pertaining to positive COVID-19 cases.

Exit interview was conducted with Administrator Narek.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021
LIC809 (FAS) - (06/04)
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