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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610143
Report Date: 10/07/2022
Date Signed: 10/07/2022 02:16:50 PM


Document Has Been Signed on 10/07/2022 02:16 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
N LA & CEN COA AC/SC, 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: 6DATE:
10/07/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Naira ParoyanTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Evelin Rios and Michael Cava conducted an announced visit in conjunction to a complaint at 11:30am. Facility placed on a Compliance Plan on 05/10/2022. As part of that Compliance Plan quarterly visits were to be made. LPA met with the Administrator Naira Paroyan for todays Compliance Plan visit.

At 11:30am, with the assistance of the Administrator, LPAs took a tour of the physical plant. The smoke alarms are hardwired and interconnected. They were observed to function properly. The carbon monoxide detector is located in every resident bedroom and common areas. They were observed to function properly. The fire extinguishers are located in the hallway and kitchen.The charge date is 05/11/2022.

Kitchen: The kitchen appliances and fixtures were functional. LPAs found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer. Resident medications and medication records, were kept locked in a kitchen cabinet..

Bedrooms: There were five (5) bedrooms four (4) designated for residents' use. Two (2) bedroom are private and two (2) bedrooms are shared. All four rooms were properly furnished with appropriate bedding and linens with sufficient lighting.

Bathrooms: There are two and a half (2.5) bathrooms at the facility. One full bath is designated for the residents' use the other full bath for staff and the one with just a sink and toilet located in a residents private room. The bathroom designated for resident use was properly supplied and had functional fixtures. Hot water temperature was measured at 147 degrees Fahrenheit. The cabinets beneath the bathrooms' sink were checked. No cleaning supplies or hazardous items were stored there.

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2022
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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: VELVET CARE
FACILITY NUMBER: 197610143
VISIT DATE: 10/07/2022
NARRATIVE
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Common Areas: These included the living room and dining area. The common areas were properly furnished. The furniture was maintained and in good repair. Floors were clean. Staff office is located across from the living room. Staff office is kept clean and free of hazards. There is a fireplace, in the staff office and it is screened. No tools observed. The dining room area was inspected and observed clean and sanitary. Dining room furniture was clean, maintained and in good repair. Passage ways to the front and back yards were clear of obstruction.

Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. The outdoor area was free of hazards. LPAs checked both side gates at each side of the home. No locks were observed on either gates. The laundry room is located adjacent to the kitchen. Detergents and cleaning supplies were observed locked and inaccessible to clients in the laundry room.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, the follow deficiency was observed during the visit citation issued on the 809D.

Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/07/2022 02:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: VELVET CARE
FACILITY NUMBER: 197610143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/07/2022
Section Cited

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(e)Water supplies and plumbing fixtures shall be maintained as follows:
(2) Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree not more than 120 degree F
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This requirement was not met as evidenced by: Based on LPAs and Administrator observationthe hot water temperature in the residents' full bathroom was measured at 147 degrees Fahrenheit.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2022
LIC809 (FAS) - (06/04)
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