197609897-12-18-2022-31-AS-JGTN-CM8RMM-20221218120857

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609897
Report Date: 12/18/2022
Date Signed: 12/18/2022 12:09:06 PM

Document Has Been Signed on 12/18/2022 12:09 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:	SUNLAND COTTAGE		FACILITY NUMBER:	197609897
ADMINISTRATOR:	ZHIRAYR AYVAZYAN		FACILITY TYPE:	740
ADDRESS:	10942 QUILL AVE		TELEPHONE:	(818) 395-0517
CITY:	SUNLAND	STATE: CA	ZIP CODE:	91040
CAPACITY:	6	CENSUS: 5	DATE:	12/18/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:02 AM
MET WITH:	ZHIRAYR "JERRY" AYVAZYAN		TIME COMPLETED:	12:00 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) Gary Tan conducted an unannounced One (1) year Required Infection Control visit at this facility. LPA met with administrator Jerry Ayvazyan and explained the purpose of this visit. A tour of the physical plant was conducted at 9:25 AM and the following was observed: The facility has one main entrance being used, the main door has required Covid-19 prevention signage (hand washing, coughing etiquette and physical distancing) are posted on the door. The PPE screening station is located immediately upon entrance and had a table equipped with sufficient PPE readily accessible, a thermometer, hand sanitizer, gloves, mask and sign in sheet at the time of visit. Visitors are required to wear mask. The facility has an approved mitigation plan on file. The facility is a single storey building and has three (3) bedrooms and two (2) bathrooms. Fire cleared for six (6) non-ambulatory residents, one (1) of which maybe bedridden on Room #3. Hospice waiver for two (2) residents. There are currently two (2) hospice residents during visit and all residents are non-ambulatory. Living and dining room furniture were checked. The living room is neat and clean along with the dining room. Furniture were observed to be in good repair and excellent condition. The facility maintains a comfortable temperature at 75°F. The smoke alarms are hardwired and interconnected and observed to be operational. There is a carbon monoxide detector installed at the facility. Fire extinguisher is located at the dining area and observed to be full and last bought on 0/31/22. (continued on LIC 809-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2022

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: SUNLAND COTTAGE	FACILITY NUMBER: 197609897
	VISIT DATE: 12/18/2022

NARRATIVE

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(continued from LIC 809)

Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked in the kitchen drawer and inaccessible to residents. Laundry room is located in the converted garage. Laundry detergent, cleaning solutions and other toxins are observed to be locked and secured in a locked cabinet located inside the converted garage which is also being used as frozen food and PPE storage.

The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit. Clients have sufficient amounts of personal hygiene product which is provided by the licensee.

The Bathroom was checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the toilet and shower. The hot water temperature was measured at a range of 116.1°F to 117.0°F . Towels and washcloths are not shared. There was enough clean linen available in stock at the cabinet.

Medications: LPA observed that the medication are kept in the kitchen filing cabinet and was observed to be locked and inaccessible to residents. There was a complete first aid kit located on top of the medication cabinet.

Garage: The garage is converted to a storage and laundry room.

The Backyard had a covered shaded area for clients with outdoor furniture. There is no body of water at the facility. There is a storage shed near the shaded area being used as a storage for used equipment of residents. The shed was observed to be locked during the visit.

Exit interview conducted. Copy of this report issued

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2022

LIC809 (FAS) - (06/04)

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