197610051-6-30-2020-29-AS-BBAI-BR3PHZ-20200630112045

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610051
Report Date: 06/30/2020
Date Signed: 06/30/2020 11:21:34 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE. SUITE 200
GOLETA, CA 93117

FACILITY NAME:	VALLEY VILLAGE SENIOR LIVING, INC.		FACILITY NUMBER:	197610051
ADMINISTRATOR:	AYVAZYAN, SARGIS		FACILITY TYPE:	740
ADDRESS:	5541 VANTAGE AVE.		TELEPHONE:	(747) 253-0007
CITY:	VALLEY VILLAGE	STATE: CA	ZIP CODE:	91607
CAPACITY:	6	CENSUS: 0	DATE:	06/30/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Sargis Ayvazyan		TIME COMPLETED:	11:00 AM

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	A Pre licensing visit was initiated today by Licensing Program Analyst (LPA) Brian Balisi. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s pre licensing visit was conducted via Facetime at 10:00am with Licensee Sargis Ayvazyan This is a single-story residence. Fire Clearance is approved for six (6) residents. (5) non-ambulatory and (1) bedridden. Facility has three (3) bedrooms and two (2) bathrooms for resident use. The physical plant was toured inside and out with Licensee. LPA observed smoke detectors and carbon monoxide detectors functioning throughout the facility. LPA observed fire extinguisher to be fully charge and purchased on 4/24/2020. LPA observed a properly stocked first aid kit hanging next to fire extinguisher. LPA observed office area to the right of the front door. LPA observed hand sanitizer stored near the entrance. All rooms are set up with beds, night stands, comfortable/appropriate chairs, chest of drawers and closet space. Lighting in the rooms appeared adequate at the time of the visit. All rooms have overhead lighting. Bathrooms are equipped with grab bars and non-skid materials. Hot water tested in the bathrooms measured at 116.4 degrees Fahrenheit. The common areas were appropriately furnished, and lighting was adequate at the time of the visit. Emergency telephone numbers and personal rights information are posted near entrance. Licensee to post flyers regarding Covid-19 by end of day today.

SUPERVISOR'S NAME: Alex Estrada	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2020

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 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE. SUITE 200
GOLETA, CA 93117

FACILITY NAME: VALLEY VILLAGE SENIOR LIVING, INC.	FACILITY NUMBER: 197610051
	VISIT DATE: 06/30/2020

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
26
27
28
29
30
31
32

LPA observed kitchen knives and sharp objects stored in a locked cabinet to the right of the dishwasher. There is an adequate supply of perishable and non-perishable foods located in the fridge. LPA observed a sufficient supply of dried goods and other non-perishable items in the pantries. The emergency food supply is kept at this location as well. The supply of dishes was adequate at this time. LPA observed cleaning supplies in a locked cabinet under the sink.

Resident and staff records will be stored in a locked cabinet near the kitchen. Medications will be stored at this location as well. There is an adequate supply of bed and bath linens as well as personal hygiene products in a hallway closet in the laundry area. LPA observed cleaning supplies and chemicals in a locked cabinet at this location.

LPA observed an adequate sized area for resident to conduct outdoor activities directly outside of the main entrance. Exit passageways were clear of hazards and obstructions. LPA observed motorized gate to be equipped with a foot pedal on the motor to manually open the gate in the event the gate loses power. Single door gate only locks from the outside. There are no bodies of water on the premises.

Component III conducted in conjunction with visit.

Pursuant to Title 22, Division 6, facility observed to be compliant with regulation. No corrections needed at this time. A copy of this report will be forwarded to the application specialist with LPA's recommendation for licensure. A telephonic exit interview was conducted with Licensee, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Alex Estrada	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2020

LIC809 (FAS) - (06/04)

Page: 2 of 2