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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609927
Report Date: 04/04/2022
Date Signed: 04/04/2022 04:09:47 PM


Document Has Been Signed on 04/04/2022 04:09 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: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:
04/04/2022
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Anzhelika AlikhanyanTIME COMPLETED:
04:15 PM
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At 3:00 p.m. on 04/04/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an announced Case Management visit. LPA met with Administrator and disclosed the reason for the visit.

During a case management visit on 03/28/2022, LPA met with residents and discussed a resident council. Resident #1 (R1) and Resident #2 (R2) requested a resident council meeting on 04/04/2022 at 3:00 p.m.

At approximately 3:05 p.m. LPA toured the facility and invited 5 out of 5 residents to the resident council meeting. 4 out of 5 residents attended the meeting, along with administrator and designated administrator. LPA distributed copies of Health and Safety Code Subsection 1569.157 on Rights of Resident Councils. LPA explained the purpose of resident councils and asked residents about facility conditions.

Activities: R1 suggested more outdoor activities like walks in the back yard and a blank calendar for resident input.

Physical Plant: 4 out of 4 residents stated the ambient temperature is nice. All furniture is clean and in good repair. R1 requested lounge chairs for the backyard.
Food Service: Residents attested the new staff is an excellent cook. R1 suggested a blank weekly menu for resident input.

Staff: R1 stated staff are “extremely helpful” and Administrator is very responsive at any time of the day.

Medication: 4 out of 4 residents stated staff assist adequately with medication.

LPA conducted exit interview and issued a copy of report.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2022
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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