<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609927
Report Date: 03/28/2022
Date Signed: 03/28/2022 03:52:46 PM


Document Has Been Signed on 03/28/2022 03:52 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:ASSISTED SENIOR CARE FACILITYFACILITY NUMBER:
197609927
ADMINISTRATOR:ANZHELIKA, ALIKHANYANFACILITY TYPE:
740
ADDRESS:7039 CLAIRE AVETELEPHONE:
(818) 988-9724
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:6CENSUS: 5DATE:
03/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Nahid AzadijafarabadTIME COMPLETED:
03:55 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
At approximately 3:05 p.m. on 03/28/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with staff and disclosed the reason for the visit. Staff screened LPA for symptoms of COVID-19. LPA toured the facility inside and out.

Census: 5

LPA spoke with 3 out of 5 residents. All residents were safe and in good condition. 2 residents were resting in bed. 2 residents were watching television in the living room. 1 resident was bathing.

At approximately 3:25 p.m. LPA spoke with Resident #1 (R1) in Bedroom #3.

At approximately 3:30 p.m. LPA spoke with Resident #2 (R2) and Resident #3 (R3) in the living room.

During today's visit, the facility is in compliance with Title 22 regulations, no citations issued.

Exit interview conducted. Copy of report issued.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
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 1