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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610143
Report Date: 05/13/2021
Date Signed: 05/13/2021 03:58:52 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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:VELVET CAREFACILITY NUMBER:
197610143
ADMINISTRATOR:BERGHOUDIAN, JACK JFACILITY TYPE:
740
ADDRESS:15731 LEMARSH ST.TELEPHONE:
(818) 891-9186
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 5DATE:
05/13/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jack BerghoudianTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Martina Berry conducted an announced Pre-licensing visit at 9:00 AM and met with Administrator Jack Berghoudian. This is a change of ownership application from North Hills Chalet LLC to Velvet Care. The LPA conducted an entrance interview with the Administrator.

The LPA conducted a facility Tour. The LPA inspected facility for Fire Safety, Personal Accommodations and Services, Medication Procedures, and Food Service. This is a single-story residence. Fire Clearance is approved for five (6) non-ambulatory and one (1) bedridden. Facility has four (4) bedrooms and two (2) bathrooms for resident use. There is one (1) additional bedroom and bathroom for staff use. Resident bathrooms have properly installed grab bars and showers have non-skid mats. Hot water temperature measured between 86.5 – 113.9 degrees Fahrenheit during the visit.

The common areas were appropriately furnished and had adequate. The LPA observed entertainment equipment and games for activities. The medications are stored in a locked cabinet in the kitchen. Sharp kitchen knives are stored in a locked cabinet underneath the kitchen sink. The LPA observed that resident and staff records were locked in a file cabinet located in the living area. The first-aid kit is complete. The facility has adequate linen, water, perishable and nonperishable food supplies.

The facility has working alarms on all exits. Smoke detectors and Carbon Monoxide detectors were checked and function properly. There are three (3) fully charged fire extinguishers located in the kitchen area, dining area and the hallway.

There is a washer and dryer in the laundry area located in the garage. All chemicals, additional personal hygiene items and emergency food supplies are locked in a cabinet in the garage. There is sufficient outdoor space with seating and a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (8185964342
LICENSING EVALUATOR NAME: Martina BerryTELEPHONE: (661) 361-6007
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021
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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: VELVET CARE
FACILITY NUMBER: 197610143
VISIT DATE: 05/13/2021
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During today's visit LPA observed the following items that require correction prior to licensure:

· The administrator will ensure that the hot water temperature is between the required range of 105 -120 degrees Fahrenheit at all times. The hot water temperature in the common bathroom is measuring at 86.5 degrees Fahrenheit; the plumbing fixture may require repair.
· The administrator will fix the screen door leading to the outdoor area.
· The administrator will secure loose wires in room 2.
· The administrator will repair chipped paint and holes in the wall in room 4.
· The administrator will remove or repair broken furniture in the outdoor area.

The administrator will provide the LPA with proof of corrections by 05/21/2021.


An exit interview was conducted. A copy of this report was provided via email for signature.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (8185964342
LICENSING EVALUATOR NAME: Martina BerryTELEPHONE: (661) 361-6007
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2