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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609689
Report Date: 12/14/2023
Date Signed: 12/14/2023 02:04:29 PM


Document Has Been Signed on 12/14/2023 02:04 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.RO, 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: 5DATE:
12/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Gayane AgazaryanTIME COMPLETED:
01:00 PM
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On 12/14/2023 at 09:00 AM, Licensing Program Analyst (LPA) Christopher Alemoh conducted an unannounced Required – Annual Continuation Inspection and met with Gayane Agazayan Administrator. Five (5) residents and two (2) staff were present during this inspection.

Facility is licensed to serve six (6) non-ambulatory residents, five (5) may be bedridden in any room. The facility also has an approved hospice waiver for six (5) residents. The facility currently has 2 non-ambulatory residents. Residents are receiving Hospice services. The Annual Licensing Fees are current.

The home consists of 1 floor level with: 1 staff room, 4 resident rooms, 2 restrooms, kitchen, dining room, and laundry room.

The administrator accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards.

At 09:12 Staff began physical plant tour.

Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises.

Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, hot water temperature properly measured between 106.2-107F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked.

Common areas were clean and clear of hazards, doorways were free of obstructions.

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Christopher AlemohTELEPHONE: 818-669-6375
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HOLLYWOOD HEALTHY LIVING LLC
FACILITY NUMBER: 197609689
VISIT DATE: 12/14/2023
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LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxics were locked and secured. First Aid kit was available stored in the garage. One fire extinguisher, last serviced July 23, 2024 was observed in the kitchen area. Second extinguisher located in the hallway charge date July 23, 2024. LPA tested all carbon monoxide detectors and smoke detector located in the kitchen area. Both devices were functional. LPA observed that all bedrooms and hallways are equipped with a carbon monoxide and smoke detector.

At 10:45 AM LPA conducted a file review.

4 staff records were reviewed, 4 out of 4 staff records had current first aid certificates and had required criminal record clearances or criminal record exemptions.

4 resident records were reviewed and, 4 out of 4 client records had Admission Agreements, Medical Assessments, Pre-appraisals (or Reappraisals) and/or Needs & Services Plans.

An exit interview was conducted, Plans of Corrections were reviewed and developed with the Licensee. A copy of this report and appeal rights were discussed and left with Administrator Gayane Agazayan.

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Christopher AlemohTELEPHONE: 818-669-6375
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC809 (FAS) - (06/04)
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