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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610002
Report Date: 07/16/2020
Date Signed: 07/16/2020 03:20:02 PM

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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:JASMINEFACILITY NUMBER:
197610002
ADMINISTRATOR:SARGSYAN, ARMANFACILITY TYPE:
740
ADDRESS:7331 KATHERINE AVETELEPHONE:
(818) 441-3590
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY:6CENSUS: 0DATE:
07/16/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Arman Sargsyan and Jasmine SargsyanTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Aja Richardson conducted a Prelicensed visit at 10 am and met with the Administrator Arman Sargsyan and Licensee Jasmine Sargsyan. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted telephonically. This application is for a Residential Care Facility for the Elderly (RCFE) with a capacity of 6. Approved for 6 non ambulatory. The administrator is applying for a hospice waiver for 2.

At 10 am, a tour of the physical plant was conducted. During the visit LPA observed the following:

KITCHEN: The facility is equipped with a spacious kitchen that is supplied with adequate dining and cook ware. Appliances and fixtures are clean and functional. The kitchen trash can was equipped with a lid.

BEDROOMS: There are six (3) bedrooms, all are appropriately furnished for double occupancy. All bedrooms were supplied with all required bedding and linens. There is sufficient lighting as well as closet and drawer space available.

BATHROOMS: There are (3) full bathrooms.Bathrooms are missing toilet grab bars. There is sufficient supplies of towels, paper goods and personal hygiene supplies. Hot water delivered at 117, 120, and 120.degrees F.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja RichardsonTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2020
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: JASMINE
FACILITY NUMBER: 197610002
VISIT DATE: 07/16/2020
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COMMON AREAS: These include a living space equipped with a television. There is a dedicated area for the posting of required documents during the front entry way.

LAUNDRY ROOM: There is a laundry room located equipped with a washer and dryer. Detergents and cleaning supplies will be stored in this room/

SURROUNDING GROUNDS: The property is equipped with fencing and gates . There is furniture appropriate for outdoor use including a covered patio providing shade.

Component III was completed during visit.

Applicant will submit photos of toilet grab bars and a non skid mat for shower.

Exit Interview Conducted. Report emailed to Administrator.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja RichardsonTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2020
LIC809 (FAS) - (06/04)
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