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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610150
Report Date: 02/22/2021
Date Signed: 02/22/2021 11:26:27 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:CALIFORNIA DREAM ASSISTED LIVINGFACILITY NUMBER:
197610150
ADMINISTRATOR:AGHABEKYAN, GAYANEFACILITY TYPE:
740
ADDRESS:7043 TAMPA AVETELEPHONE:
(818) 300-8393
CITY:RESEDASTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 5DATE:
02/22/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:59 AM
MET WITH:Gayane AghabekyanTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Patrick Shanahan conducted a Pre-Licensing Visit & Inspection and Comp III. This is a change of ownership. Applicant Representative, Gayane Aghabekyan met with the LPA.
Due to the Covid -19 pandemic, this pre-licensing was conducted via video phone. No digital signature was attained and a copy of the report was emailed to the administrator. A "wet" signature is on file in the main facility folder.

LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. First-aid kit is complete; facility has adequate linen, perishable and nonperishable food supplies. Hot water measured at 120 degrees Fahrenheit. There is no swimming pool or other body of water. The backyard is fenced and gated with self-latching mechanisms. There is patio area in the backyard with table and chairs for resident use. All chemicals and sharps are stored in a locked cabinet. Medications are stored in a locked med-room inside the office. Facility has 4 bedrooms and 3 bathrooms. Fire Clearance is approved for 5 non ambulatory residents and 1 bedridden. There are 2 shared rooms and 2 single rooms. The washer and dryer are located in a locked room next to the kitchen.

Facility is in compliance with Title 22 Regulations at this time. This report will be sent to the Centralized Application Unit (CAU). You will be notified by the CAU Analyst when your license has been approved.
You are not allowed to begin operating until you have been notified that your license has been approved by the CAU Analyst. Failure to comply could affect approval of your license.
Exit interview held and report issued.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2021
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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