197609895-11-8-2023-31-AS-CALH-CXDTEH-20231108133956

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609895
Report Date: 11/08/2023
Date Signed: 11/08/2023 01:40:49 PM

Document Has Been Signed on 11/08/2023 01:40 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:	SUN VALLEY CARE COTTAGE LLC		FACILITY NUMBER:	197609895
ADMINISTRATOR:	BAGHDASSARIAN, FLORIDA		FACILITY TYPE:	740
ADDRESS:	8553 GLENCREST DRIVE		TELEPHONE:	(818) 785-2344
CITY:	SUN VALLEY	STATE: CA	ZIP CODE:	91352
CAPACITY:	6	CENSUS: 0	DATE:	11/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Florida Baghdassarian		TIME COMPLETED:	01:39 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

On 11/08/2023 at 09:30AM, Licensing Program Analyst (LPA) Christopher Alemoh conducted an unannounced Required – Annual Continuation Inspection and met with Florida Baghdassarian, Administrator. One (1) staff was present during this inspection. No residents at the time of visit. Temp of the facility was at 70 degrees Fahrenheit.

Facility is licensed to serve six (6) non-ambulatory residents, one (1) may be bedridden in any room. The facility also has an approved hospice waiver for two (2) residents. The facility currently has no non-ambulatory residents. The Annual Licensing Fees are current. Administrator performed Thermometer check upon entry to the facility.

The home consists of 1 floor level with: (3) resident rooms, (2) restrooms, kitchen, dining room, and laundry area located in the main hallway. Rm # 3 has been designated for bedridden residents.

The administrator accompanied LPA inside and outside the facility during this inspection. The rear yard of the facility was toured. LPA observed a pool next to a pool house. The body of water is surrounded by a black 5 ft tall fence inaccessible to residents. The pool house has been converted into a staff quarter and has an extra refrigerator for resident food. Pool house is also locked and secured. Walkways around the home were clear of hazards.

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 Rm #3-bathroom temp tested at 108 degrees Fahrenheit. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Christopher Alemoh	TELEPHONE: 818-669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUN VALLEY CARE COTTAGE LLC	FACILITY NUMBER: 197609895
	VISIT DATE: 11/08/2023

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

(Cont. from 809)

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

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 kept in locked storage cabinet under the sink. Kitchen temp was at 110 degrees Fahrenheit. Facility First Aid kit is stored in a cabinet in the main hallway. Fire extinguishers are in working order. One fire extinguisher was observed in the kitchen area. The second extinguisher located in the main hallway both functional and purchased September 26 th 2023. LPA tested carbon monoxide detectors and smoke detector located in the kitchen area. LPA observed that all bedrooms and hallways are equipped with a carbon monoxide and smoke detector. Both devices were functional. and hardwired.

One (1) staff record was reviewed, Administrator Baghdassarian staff records had current first aid certificates and had required criminal record clearances or criminal record exemptions, LIC 501, and LIC 9052

An exit interview was conducted, A copy of this report and appeal rights were discussed and left with Administrator Florida Baghdassarian.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Christopher Alemoh	TELEPHONE: 818-669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2