197609785-7-12-2021-31-AS-RVAA-C4UU4D-20210712151457

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609785
Report Date: 07/12/2021
Date Signed: 07/12/2021 03:15:11 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:	EATON CANYON VILLAS I		FACILITY NUMBER:	197609785
ADMINISTRATOR:	GARIBYAN, ARMOND		FACILITY TYPE:	740
ADDRESS:	2518 GANESHA AVE		TELEPHONE:	(818) 429-0070
CITY:	ALTADENA	STATE: CA	ZIP CODE:	91001
CAPACITY:	6	CENSUS: 4	DATE:	07/12/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Crystal Paul, Manager		TIME COMPLETED:	03:30 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) Rosaura Valenzuela conducted an unannounced Required One (1) year-Infection Control inspection to the facility. LPA met with House Manager Crystal Paul and explained the reason for the visit. A tour of the physical plant was conducted at 1:38pm and the following was noted: There is only one entrance being utilized at the facility, there are required posters posted at the main door. Screening area is located immediately upon entrance. Sign in sheet and hand sanitizer are available. LPA was screened upon entry. The facility has submitted Mitigation Plan. Signs to wear a mask and other COVID-19 prevention protocol signs were posted outside the door. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted all over the facility. The facility has sufficient stock of PPE in the garage. The facility has four (4) bedrooms and three (3) bathrooms currently occupying four (4) residents. Two (2) rooms are shared rooms and two (2) rooms are private rooms. (continued on LIC 809-C

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021

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: EATON CANYON VILLAS I	FACILITY NUMBER: 197609785
	VISIT DATE: 07/12/2021

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
26
27
28
29
30
31
32

Living and dining room furniture were also checked. The living room is neat and clean. The facility maintains a comfortable temperature at 74 degrees. The smoke detectors are hardwired and interconnected and observed to be operational. There is a carbon monoxide detector in the facility. Fire extinguisher is located in the kitchen. It was purchased in October 2020.

The back patio of the facility has outdoor furniture with a covered shaded area for residents. There is no body of water at the facility. There is detached garage that is being used for storage purposes.

Laundry room is located outside of the facility and is kept locked.., Laundry detergents, cleaning agents and other toxins are also kept locked inside of the laundry room.

Food Service/Kitchen area was sufficiently stocked with two (2) days of perishable and seven (7) days of non-perishable food. Knives and sharp objects were observed to be locked and inaccessible to residents.

The residents rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passage ways are lit.

The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the shower and toilet. The hot water temperature was measured at 113.2 degrees. There was enough clean linen available inside one of the closets.

Medications-LPA observed medications to be stored inside two locked cabinets and it is inaccessible to residents.. There was one ( 1) complete first aid kit located inside the kitchen cabinet.

Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021

LIC809 (FAS) - (06/04)

Page: 2 of 2