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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610042
Report Date: 08/24/2022
Date Signed: 08/24/2022 11:27:45 AM

Document Has Been Signed on 08/24/2022 11:27 AM - 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:DAVID'S ADULT RESIDENTIAL FACILITY INC.FACILITY NUMBER:
197610042
ADMINISTRATOR:MANAVCHYAN, HERMINEFACILITY TYPE:
735
ADDRESS:16705 KINZIE ST.TELEPHONE:
(323) 326-6364
CITY:NORTHRIDGESTATE: CAZIP CODE:
91343
CAPACITY: 4CENSUS: 4DATE:
08/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Hermine ManavchyanTIME COMPLETED:
11:37 AM
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At 9:50 a.m. on 08/24/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with the Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out.

The facility was last visited on 07/29/2021 for an annual visit. It is a single story building with 4 bedrooms, 2 bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for 4 ambulatory clients age 18 - 59.

LPA observed a maintained front yard. A masking requirement sign was posted at the front door. Once inside, LPA was screened for symptoms of infectious disease upon entry. The screening station contained a digital thermometer, gloves, surgical masks, hand sanitizer, and a visitor log. Postings near the front hallway included confidential complaints, neighborhood grievances, personal rights, Emergency Disaster Plan, house rules, Administrator certificate, and facility license. Walls, floors, ceilings, windows, and screens were clean and in good repair. The living room contained socially distanced furniture in good repair. In the kitchen, LPA observed an adequate supply of perishable and non-perishable food. The stove and hood were sanitary. Sharps were locked above the stove and accounted for on a checklist. Activity schedule, facility menu, and sanitation checklist were also posted in the kitchen. Near the kitchen pantry were a washer and dryer in good condition. Detergents and cleaning supplies were locked above the appliances. The back yard had a covered patio area with furniture in good repair. Emergency exit paths were free from obstructions. Exit doors were unlocked with inward facing latches. The garage was converted to an office space. It contained extra water bottles, an extra refrigerator, paper supplies, and resident and staff files. The garage was locked, and files were locked in a cabinet.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2022
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 3
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: DAVID'S ADULT RESIDENTIAL FACILITY INC.
FACILITY NUMBER: 197610042
VISIT DATE: 08/24/2022
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The facility has 4 private bedrooms. All bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition. The hallway between bedrooms had two storage closets with drinks, activities, extra linens, and hygiene supplies. Medication and emergency backpacks were locked in a separate closet by the front door. The facility has 3 bathrooms. All bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower. Non-skid mats were available for use. At 10:17 a.m. LPA measured the water temperature in Bathroom #1 to be 105.1 degrees Fahrenheit. At 10:34 a.m. LPA tested the dual functioning smoke and carbon monoxide detector to be operational. When tested, 3 out of 3 detectors functioned and provided verbal alerts. At 10:37 a.m. LPA observed a fully charged fire extinguisher in the kitchen. The facility uses a security system, and LPA heard 2 out of 2 auditory alarms functioning at the front and backs doors.

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

Exit interview conducted. Copy of report issued.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
LIC809 (FAS) - (06/04)
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