197610150-3-4-2024-31-AS-HRAI-D32VX4-20240304154855

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610150
Report Date: 03/04/2024
Date Signed: 03/04/2024 03:49:47 PM

Document Has Been Signed on 03/04/2024 03:49 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	CALIFORNIA DREAM ASSISTED LIVING		FACILITY NUMBER:	197610150
ADMINISTRATOR:	AGHABEKYAN, GAYANE		FACILITY TYPE:	740
ADDRESS:	7043 TAMPA AVE		TELEPHONE:	(818) 300-8393
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY:	6	CENSUS: 5	DATE:	03/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Rima Agaronyan, Administrator Designee		TIME COMPLETED:	04:10 PM

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At 10:55 AM Licensing Program Analyst (LPA), Huma Rahimi, conducted an unannounced annual inspection at the facility mentioned above. LPA met with Staff Lilit Egoyan, and later the Administrator Designee Rima Agaronyan, arrived at the facility and explained the reason for the visit. Physical tour was conducted with the Administrator Designee and LPA observed the following:

Kitchen: 11:50 AM, LPA toured the kitchen area. The kitchen contained two fridges with adequate supplies of staple non-perishable for minimum 1 week and perishable for 2 days. Cabinets contained clean dishes, and adequate supplies of non-perishable food. At the end of the kitchen was a door to the laundry room. The room contained a washer and a dryer, and all detergents and cleaning supplies were in locked cabinets.

Medications: At 12:05 PM Near the kitchen, LPA observed a locked office with resident medications, files, and water bottles.

Bedrooms: The facility had five (5) bedrooms. One (1) bedroom is designated for staff. The staff bedroom was locked and contained no hazardous items. Two (2) resident bedrooms, Bedroom # two (2) and Bedroom #3 are shared. Two (2) resident bedrooms, Bedroom # one (1) and Bedroom # four (4) are private. All bedrooms contained adequate storage space, clean linens, televisions, nightstands, and lamps. Bedroom# one (1), Bedroom # two (2), and Bedroom # three (3) had exit doors in the room with ramps leading out.

Bathrooms: The facility had two (2) bathrooms. Bathroom # one (1) is near the facility entrance and Bedroom # one (1). Bathroom # two (2) was between Bedroom # three (3) and Bedroom # four (4). Both bathrooms contained fully stocked soap, paper towels, trash can, non-skid mats, and grab bars. Hot water temperature measured at 117.3°F.

Continue on LIC 809C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CALIFORNIA DREAM ASSISTED LIVING	FACILITY NUMBER: 197610150
	VISIT DATE: 03/04/2024

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Common Areas: The facility maintains a comfortable temperature at 76°F. The living room and dining area appeared clean and were properly furnished. The living room has a television, comfortable furniture. No obstructions and or tripping hazards throughout the facility. LPA observed a fully charged fire extinguisher and purchased on 09/21/2023.

Smoke detectors/carbon monoxide. Smoke detectors were located throughout the facility, and at 12:22 PM they were tested and observed to be operational. Carbon monoxide was located in a hallway and was also tested and observed to be operational.

Outside space: LPA observed a covered patio area for visitation and an extra table with furniture in good repair. All outdoor spaces and paths were from obstructions.

Garage: LPA observed a garage with adequate incontinence supplies and PPE.

Between 12:30 PM to 2:30 PM, LPA reviewed records of five (5) residents and five (5) staff. Residents and staff records appeared to be complete and updated.

Administrative: LPA collected Certificate of Liability Insurance, and LIC500.

No deficiency cited during today’s visit.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024

LIC809 (FAS) - (06/04)

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