<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609640
Report Date: 08/03/2021
Date Signed: 08/03/2021 01:37:26 PM

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:MIRACLE ASSISTED LIVING FACILITYFACILITY NUMBER:
197609640
ADMINISTRATOR:GAYANE AGHABEKYANFACILITY TYPE:
740
ADDRESS:20648 LONDELIUS STTELEPHONE:
(747) 206-5390
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY:6CENSUS: 6DATE:
08/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Rima AgaronyanTIME COMPLETED:
01:00 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) Wendell Smith made an unannounced required annual visit. LPA met with administrator designee and explained the reason for this visit.

he physical plant was toured inside and out. Property consist of five (5) bedrooms of which four (4) are designated for residents use and three (3) bathrooms designated for residents use; facility has a kitchen, dining/living room and designated office area. The facility has been fire cleared for five (5) non-ambulatory and one (1) bedridden. There are two (2) shared rooms and two (2) private rooms designated for residents. LPA observed all resident bedrooms to be appropriately furnished. LPA observed bathrooms to have grab bars and non skid material. Hot water temperature was tested and found to be at 116 degrees F.
LPA toured facility common areas and found them to be appropriately furnished. The facility smoke alarms/carbon monoxide were tested and found to be in working order. LPA checked the kitchen area for the ability to prepare and store food. LPA observed there to be a sufficient amount of perishable and non perishable food. LPA observed there to be a sufficient amount of emergency supply food also. LPA observed a washer and dryer . The supply of extra bed and bath linen is adequate. All required postings observed on the wall near the office area. Alarms on all exterior doors were engaged at the time of visit. The outside was toured and observed free of visible hazards. There is a pool on the premises which was observed fenced/locked. Backyard is set-up with patio furniture for residents use. Facility currently has four residents on hospice at the time of the visit.

Exit interview conducted.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021
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 1