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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610051
Report Date: 06/22/2022
Date Signed: 06/22/2022 01:57:00 PM


Document Has Been Signed on 06/22/2022 01:57 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:VALLEY VILLAGE SENIOR LIVING, INC.FACILITY NUMBER:
197610051
ADMINISTRATOR:AYVAZYAN, SARGISFACILITY TYPE:
740
ADDRESS:5541 VANTAGE AVE.TELEPHONE:
(747) 253-0007
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY:6CENSUS: 5DATE:
06/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Sargis Ayvazyan-AdminsitratorTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility to conduct a required annual visit. This
annual had a specific emphasis on infection control practices and procedures. The LPA met with Facility
staff at approximately 11:00 a.m. and explained the reason for the visit. The administrator Sargis Ayvazyan arrived shortly thereafter.

The LPA toured the physical plant areas inside and outside at approximately 11:25 p.m., with staff Tamara Bernard, to ensure that there are no health and safety hazards.

KITCHEN: At 11:25 a.m., the LPA toured the Kitchen. Appliances were clean, sanitary and in operable condition. The facility has a sufficient supply of perishable and non-perishable foods. At approximately 11:25 a.m. knives were observed to be locked and inaccessible to residents in care.

LAUNDRY: At 11:35 a.m., the LPA observed the laundry area which is located in the hallway closet. Appliances were clean, sanitary and in operable condition. Laundry detergents and chemicals were observed to be locked in an adjacent cabinet in the hallway.

BEDROOMS: There are three (3) bedrooms designated for resident use. Bedroom #1 is single occupancy with no private bathroom and an exit to the exterior. Bedroom #2 and bedroom #3 are double occupancy with no exit to the exterior. Bedroom #3 has a shared bathroom. The facility has furnished each room with clean linens, appropriate furnishings, and sufficient lighting for resident use. Storage space cabinet in hallway was observed containing clean linens for resident use.

Continued on LIC 809-C.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2022
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 4


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: 06/22/2022
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BATHROOMS: Resident bathrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap and paper products. Bathroom hot water measured between 116.7 degrees Fahrenheit and 119.8 degrees Fahrenheit between 11:43 a.m. and 11:45 a.m.

BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. There were
no bodies of water noted. The LPA observed a locked storage unit containing home improvement materials such as paint.

COMMON SPACES: The common spaces included the living room and dining area. The LPA observed cameras in the common areas. A TV for resident use including games in a storage cabinet. All areas were clean, sanitary and in good repair. Smoke detectors are hardwired and interconnected, there is a Carbon Monoxide detector installed at the facility. Staff tested the fire alarm system at 11:47 a.m. and the LPA observed the system to be operating at the time of the visit. The fire extinguisher was observed to be full and last serviced on 8/26/21. The LPA observed required postings on the wall at the entrance. At the time of the visit, flooring was checked for cleanliness and appeared in good condition. Living room and dining room furniture was observed to be in good condition.

INFECTION CONTROL: Upon entry, the facility had a central entry point for symptom screening, temperature
checks, and sanitation station. There was 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. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of
COVID-19. The facility does not have a confirmed case of COVID-19 at this time. The LPA conducted an
unannounced initial 10-day complaint visit in conjunction with today's annual visit, complaint control number
29-NP-20220617132232. The LPA reminded the Licensee that masking protocols are still in place including vaccination requirements, visitation, and testing protocols and to ensure that department provider notices are continued to be posted.

An exit interview was conducted a copy of this report was discussed and provided to Administrator, whose
signature on this form confirm receipt of these documents.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
LIC809 (FAS) - (06/04)
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