197609945-12-26-2023-31-AS-CALH-CYW2Q4-20231226163520

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609945
Report Date: 12/26/2023
Date Signed: 12/26/2023 04:36:17 PM

Document Has Been Signed on 12/26/2023 04:36 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 RESIDENTIAL MANOR LLC		FACILITY NUMBER:	197609945
ADMINISTRATOR:	HAKOBYAN, ANNA		FACILITY TYPE:	740
ADDRESS:	8667 HERRICK AVENUE		TELEPHONE:	(818) 823-0955
CITY:	SUN VALLEY	STATE: CA	ZIP CODE:	91352
CAPACITY:	6	CENSUS: 5	DATE:	12/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Rebecca Durgaryan		TIME COMPLETED:	04:30 PM

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On 12/26/2023 at 12:35 PM, Licensing Program Analyst (LPA) Christopher Alemoh conducted an unannounced Required – Annual Continuation Inspection and met with staff Lyuba Poghosyan. Co-Administrator Rebecca D. was called at met LPA at the facility twenty minutes later. Five (5) residents and two (2) staff were present during this inspection.

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 four (4) residents. The facility currently has 4 non-ambulatory residents. 1 resident is receiving Hospice services and 1 resident is receiving Home Health Services.

Facility is following infection control plan. LPA was screened upon, and facility has signage throughout the facility. The home consists of 1 floor level with: 4 resident rooms, 2 restrooms, kitchen, dining room, and laundry room.

S2 and S3 accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured LPA observed an empty pool in the backyard. The pool is secured by a five foot tall black fence and a silver padlock on the gate. 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 106.2-107F. 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: 12/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023

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

FACILITY NAME: SUN VALLEY RESIDENTIAL MANOR LLC	FACILITY NUMBER: 197609945
	VISIT DATE: 12/26/2023

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Common areas were clean and clear of hazards, doorways were free of obstructions. Facility has a no operational fireplace in the living room. It is inaccessible to residents a covered by a black screen.

Laundry area is adjacent to kitchen and observed to be clean and appliances in good repair.

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. First Aid kit was available. One fire extinguisher last serviced 10-15-2023 was observed in the kitchen area. A second fire extinguisher was noted at the administrator desk charge date 10-15-2023 LPA tested carbon monoxide detectors and smoke detector located in the kitchen area. Both devices were functional. LPA observed that all bedrooms and hallways are equipped with a carbon monoxide and smoke detector.

4 staff records were reviewed, 4 out of 4 staff records had current first aid certificates and had required criminal record clearances or criminal record exemptions.

5 resident records were reviewed and, 5 out of 5 client records had Admission Agreements, Medical Assessments, Pre-appraisals (or Reappraisals) and/or Needs & Services Plans.

No deficiencies cited.

An exit interview was conducted. A copy of this report and appeal rights were left with Co-Administrator Rebecca Dugaryan.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Christopher Alemoh	TELEPHONE: 818-669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 12/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023

LIC809 (FAS) - (06/04)

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