<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610144
Report Date: 06/09/2022
Date Signed: 06/09/2022 12:09:31 PM

Document Has Been Signed on 06/09/2022 12:09 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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:VICTORIA'S DIGNITY CAREFACILITY NUMBER:
197610144
ADMINISTRATOR:BERGHOUDIAN, JACK JFACILITY TYPE:
740
ADDRESS:13874 KELOWNA ST.TELEPHONE:
(818) 894-5761
CITY:ARLETASTATE: CAZIP CODE:
91331
CAPACITY: 6CENSUS: 6DATE:
06/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:56 AM
MET WITH:Jack BerghoudianTIME COMPLETED:
12:12 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Tihesha “Lynn” Smith conducted an unannounced annual/infection control visit to this facility at 8:56 am and observed COVID signs on the front door. LPA was greeted by caregiver Tatyana Hakobyan and temperature was taken and recorded in foyer/waiting area. The administrator was called and arrived at 9:28 am. LPA observed that the six (6) residents were at the facility during visit.

LPA conducted a tour of the physical plant at 9:35 am to ensure there are no health and safety hazards and facility staff are following Title 22 Regulations and the following was noted:
The facility had a Mitigation plan and copy received.

Hand washing, coughing etiquette, physical distancing, and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with cover.

Facility has four (4) four bedrooms: (3) three shared bedrooms for clients and (1) bedroom designated as employee room. There are two (2) bathrooms: (1) one for clients located in hallway near client’s bedrooms #1 and #2. There is no body water in the facility.

Bedrooms were toured and observed to be clean and properly furnished. Linen storage was also checked and observed to have ample supply of clean linen and towels. LPA observed six (6) Ready America first aid backpacks. One (1) for each client stored in clients’ closet.
Bathrooms were observed to be clean and sanitary with necessary supplies. Hot water temperature range between 105 and 120-degrees Fahrenheit.
Physical plant was checked for cleanliness and condition. Facility was in good repair and observed to be clean and free of clutter during today's visit.
Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to (Cont on 809C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2022
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 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: VICTORIA'S DIGNITY CARE
FACILITY NUMBER: 197610144
VISIT DATE: 06/09/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(Cont from 809)

be in good condition and adequate seating for clients.
Kitchen area was observed to be clean and sanitary. All the toxins, cleaning solutions and disinfectants are locked in cabinet above the dryer. Laundry area is adjacent to kitchen and observed to be clean and appliances in good repair.
Food. The facility is observed to have sufficient food supply for the clients both perishable and non-perishable.
Sharps are locked in drawer in kitchen near sink.
Medication are located in kitchen locked in separate wood file cabinet. A locked mini fridge situated on top of medication file cabinet holds prescription eye drops. Medication was observed to be inaccessible to clients. First aid kit located in foyer near administrator workstation observed to be fully stocked. Temperature of facility on wall thermostat is observed and set to 77 degrees Fahrenheit. Fire extinguisher There are three (3) fire extinguishers in the facility: one (1) in foyer/waiting room, one (1) in the living room and one (1) in the kitchen. Extinguishers were observed to be charged with receipt dated: 5/10/2022. Dual Smoke alarms and carbon monoxide are hardwired and interconnected, were tested and observed to be operable. Garage used to store frozen food in 2nd refrigerator, canned foods, water, emergency supplies, and PPE surplus.
There are (3) three covered patio sections: (2) two for clients use and (1) for staff use. All observed to be clean and furnished with adequate seating. The grounds entry/exits area were clean with and free of obstruction.

There was no immediate health and safety hazard observed during the day of inspection. There are no deficiencies to report.



Exit interview conducted and a copy of this report was given.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2