197610096-3-12-2021-31-AS-MBEY-BZ2M2C-20210312081320

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610096
Report Date: 03/08/2021
Date Signed: 03/12/2021 08:13:55 AM

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:	HEALTHY LIFE SERVICE FACILITY		FACILITY NUMBER:	197610096
ADMINISTRATOR:	TADEVOSYAN, LUSINE		FACILITY TYPE:	740
ADDRESS:	15921 LIGGETT STREET		TELEPHONE:	(747) 254-6056
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY:	6	CENSUS: 5	DATE:	03/08/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Lusine Tadevosyan		TIME COMPLETED:	11:13 AM

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Licensing Program Analyst (LPA) Martina Berry conducted an announced Pre-Licensing visit due to change of ownership. Due to the situation surrounding the Corona virus Disease 2019 (COVID-19), and to implement mitigation measures, this visit was conducted virtually via FaceTime. The LPA met with facility Administrator Lusine Tadevosyan and Licensee Arusyak Ohanyan to explain the reason for the visit.

This An application for a total of (6) residents was submitted; (5) non-ambulatory residents and (1) bedridden. The facility currently has (4) non-ambulatory residents and (1) bedridden resident.

The physical plant was toured inside and out with the Administrator and Licensee. Upon entry of the facility, there were COVID-19, CDC, visiting, and Department of Public Health postings visible. There was an area designated for visitor sign-in and symptom checks. had a visitor sign in book, temperature monitor, and questionnaire for staff and visitors. The facility has (4) bedrooms, and (3) bathrooms. Three bedrooms are used for residents and the remaining bedroom is designated as a staff room. The facility does not have live-in staff. Bedrooms were furnished with the required items for resident use. Bathrooms were equipped with grab bars and non-skit mats. The hot water temperature measured at 115 degrees Fahrenheit. Personal care items and linens were available for resident use.

The kitchen was clean and appliances were functioning. The facility's perishable, non-perishable, and emergency food supply met Licensing requirements. Storage areas and counters were clean for food preparation. Knives, cleaning supplies, and medication were kept in locked cabinets.

Personnel and client records were locked in an area away from resident access. The LPA reviewed a sample of resident and staff files. Resident and staff files were complete with required items.

(Continued on LIC 809-C)

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (8185964342
LICENSING EVALUATOR NAME: Martina Berry	TELEPHONE: (661) 361-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2021

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HEALTHY LIFE SERVICE FACILITY	FACILITY NUMBER: 197610096
	VISIT DATE: 03/08/2021

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The LPA inspected the common areas including the dining room, living room, and patio areas. These areas were observed to be clean and appropriately furnished. Activities were provided for resident use. Doors and passageways were clear and free from obstruction. The back yard is completely fenced with a gate easily accessible and unlocked. No visible hazards around the surrounding grounds. Smoke detectors and carbon monoxide were operating correctly. Fire extinguisher fully charged. Facility telephone was operating. First aid kit inspected.

An exit interview was conducted. A copy of this report was provided to the administrator via email for signature. A component III Training was scheduled with the licensee and administrator on 3/9/21 at 3:00 PM.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (8185964342
LICENSING EVALUATOR NAME: Martina Berry	TELEPHONE: (661) 361-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2021

LIC809 (FAS) - (06/04)

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