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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609640
Report Date: 10/25/2022
Date Signed: 10/25/2022 02:22:04 PM


Document Has Been Signed on 10/25/2022 02:22 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: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: DATE:
10/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Rima AraronyanTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with the administrator designee, Rima Araronyan and explained the reason for the visit.

At approximately 11:45am, LPA Cava took a tour of the physical plant. Required postings were observed in the entry area. The LPA's temperature was taken at entry. Extra masks and hand sanitizer was observed with a sign in sheet. The smoke alarms are battery operated. The carbon monoxide detector functions properly. There is a fully charged fire extinguisher is located in the kitchen.

Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives are stored in a locked drawer.

Bedrooms: There were four (4) bedrooms designated for residents' use. All four resident bedrooms were were properly furnished with appropriate beddings and linens with sufficient lighting. There is one (1) room designated for staff.

Bathrooms: There are three (3) bathrooms designated for residents' use. All three bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 111 degrees Fahrenheit. No cleaning supplies were observed accessible to the residents in care.

Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. Properly labeled medications were locked in staff's work station by the front entrance.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MIRACLE ASSISTED LIVING FACILITY
FACILITY NUMBER: 197609640
VISIT DATE: 10/25/2022
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Surrounding Grounds: Entry/exits were free of obstruction. The front and back yards were inspected and observed to be free of obstruction. The laundry area is located by the storage space, near the backyard exit of the home. Cleaning supplies and detergents were observed locked there.

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.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a copy of this report issued.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2