197610051-6-25-2021-29-AS-SURA-C4BQQ9-20210625122155

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610051
Report Date: 06/25/2021
Date Signed: 06/25/2021 12:22:02 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:	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: 3	DATE:	06/25/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Sargis Ayvazyan		TIME COMPLETED:	12:10 PM

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At 8:30 am Licensing Program Analyst (LPA) Sandra Urena conducted an Infection Control call, and asked Risk Assessment Questions before arriving at the facility. At 8:50 am LPA was greeted by Caregiver. Administrator Sargis Ayvazyan arrived at around 9:30 am. LPA introduced herself and explained the reason for the visit. LPA conducted an unannounced required annual inspection visit.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station. LPA was asked to sign in and was offered sanitizing solution. Temperature was taken by Caregiver. Infection Control signs were visible at entrance and throughout the facility.

Facility Tour: At 9:45 am LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Bedrooms: At 10:10 am LPA observed the Residents' bedrooms. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

Bathrooms: At 10:20 am LPA observed the Residents’ restrooms. Restrooms were clean, shower area was in clean condition with grab bars and non-skid mat available. Paper towels were available for drying hands. Hand washing sign was displayed.

Kitchen: At 10:30 am LPA observed the kitchen/dining area. Knives are stored in a locked cabinet in the kitchen. The facility has enough supply of perishable and non-perishable food. Freezer and refrigerator are stocked with a variety of foods.

Outdoor Space: At 10:45 am LPA observed the Outdoor space. A shaded patio is available for residents to visit with family members.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021

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: VALLEY VILLAGE SENIOR LIVING, INC.	FACILITY NUMBER: 197610051
	VISIT DATE: 06/25/2021

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Facility Records: At 11:15 am LPA reviewed staff and residents’ records.

The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. The facility has not had a confirmed case of COVID-19 at this time, the facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies were cited at this time. Exit interview conducted. Signatures obtained. A copy of report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021

LIC809 (FAS) - (06/04)

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