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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609689
Report Date: 03/10/2022
Date Signed: 03/10/2022 12:35:19 PM


Document Has Been Signed on 03/10/2022 12:35 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:HOLLYWOOD HEALTHY LIVING LLCFACILITY NUMBER:
197609689
ADMINISTRATOR:AGAZARYAN, GAYANEFACILITY TYPE:
740
ADDRESS:8002 HOLLYWOOD WAYTELEPHONE:
(818) 395-1905
CITY:SUN VALLEYSTATE: CAZIP CODE:
91352
CAPACITY:6CENSUS: 4DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Gayane AgazaryanTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted an unannounced infection control inspection/visit. Upon arriving, LPA was greeted by caregiver Maxine Bailey, who allowed LPA to enter the facility. According to Maxine, there have not been any active or past COVID cases at the facility, and has been COVID free since the beginning of the pandemic. There are currently (4) residents vaccinated, and (4) staff vaccinated; no-one from the facility has received the booster shot as of yet. The current census is (4). LPA entered through the front door of the facility, and LPA observed the cleaning table, with hand sanitizer. LPA observed staff to have full mask covering. COVID-19, CDC, Department of Public Health, and Licensing postings on the walls throughout the facility. Administrator Gayane Agazaryan arrived shortly after, who concluded the mitigation inspection with LPA.

The infection control inspection began with the caregiver Maxine, who escorted LPA throughout the facility. There are (2) bathrooms, with hand-washing signs, and there are (4) bedrooms; with (1) room shared. All bedrooms were properly furnished. The common areas were observed to be clean, including bathrooms, with soap and towels. LPA conducted a mitigation plan and facility operation review with the caregiver and Administrator. Administrator informed LPA, that she prefers new admits and new hires to be vaccinated; but is not a requirement. For those who are not vaccinated, there will be weekly COVID testing.

Administrator reported to LPA, the facility has documentation of all vaccination records and other pertinent information pertaining to COVID-19, in staff and resident files. Administrator reported she receives and reviews all the departmental emails and continues to provide and conduct training to staff in relation to COVID-19. There is no current paid sick leave policy in place; Administrator has not thought about it, but will will consider putting something in place. The facility does not have current staffing issues; but Administrator will consider developing a back up plan.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022
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: HOLLYWOOD HEALTHY LIVING LLC
FACILITY NUMBER: 197609689
VISIT DATE: 03/10/2022
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There is not a current designated room for potential positive COVID residents; but Administrator has developed a plan when needed.

PPE supplies were inspected, and facility has over a (30day) supply available. Chemicals, cleaning supplies, paper products were observed and locked and secured in the garage area. Administrator informed LPA that they continue to implement the best practices for their facility, which has kept them COVID-19 free since the beginning of the pandemic. The facility is aware to report any changes with residents and staff to Licensing and there LPA, pertaining to positive COVID-19 cases.

Exit interview was conducted, and copy of report will be emailed to Administrator.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
LIC809 (FAS) - (06/04)
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