197610159-4-23-2021-31-AS-AARO-C2CLU9-20210423090335

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610159
Report Date: 04/22/2021
Date Signed: 04/23/2021 09:04:09 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:	CHATSWORTH LIVING		FACILITY NUMBER:	197610159
ADMINISTRATOR:	TOUPHANIAN, ABRAHAM		FACILITY TYPE:	740
ADDRESS:	20453 MAYALL STREET		TELEPHONE:	(818) 590-6793
CITY:	CHATSWORTH	STATE: CA	ZIP CODE:	91311
CAPACITY:	6	CENSUS: 0	DATE:	04/22/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:03 AM
MET WITH:	Abraham Touphanian		TIME COMPLETED:	11:00 AM

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Licensing Program Analyst (LPA) Elizabeth Arambulo conducted an announced PRELICENSING facetime visit to this facility and toured the facility with applicant Abraham Touphanian. The facility is a new facility with no residents.

A fire clearance was granted on 03/08/21 for 5 non ambulatory and one bedridden resident. Room #1 and #2 are designated for bedridden resident. There are 4 bedrooms for resident’s use. No live-in staff will be at the home. All evening staff are awake staff. The Pre-licensing Self-Certification Checklist was completed and signed on 03/16/2021.

LPA took a tour of the facility with the applicant/ administrator Mr. Abraham Touphanian.

The scope of the visit included a tour of the physical plant areas inside and outside to ensure there are no health and safety hazards and compliance with Title 22 Regulations. The physical plant tour was conducted via facetime due to the Covid 19 situation. Upon entry to the facility the front door had signage regarding visitation. There is no area set to screen visitors, staff, or residents. The administrator will be placing a table near the entry way with required hand sanitizer, thermometer, temperature log, extra mask and gloves. The hallway bathroom are steps away from the entry area for hand washing if needed. The bathrooms had the signage for hand washing instructions along with paper towels, toilet paper, and hand soap. It was observed there were grab bars and a non-slip surface in the shower area.

The common living room, den and dining area were observed to be clean with no safety hazards. Proper led lighting was seen throughout the home. Residents rooms were furnished with ceiling led lights, nightstand and storage drawers. Activities displayed were puzzles, board games and outdoor activity. An activity schedule was provided by the administrator

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angelica Arambulo	TELEPHONE: (818) 596-4358
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2021

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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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: CHATSWORTH LIVING	FACILITY NUMBER: 197610159
	VISIT DATE: 04/22/2021

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One bedroom (room #2) was set up as a model. The two beds had all the necessary linens and there are additional linens in the hallway closet. Clients rooms were clean and well maintained. The residents are provided a hamper in their closet.

The kitchen was checked for operation of appliances. The stove was checked and each burner lighted on its own. The kitchen appeared organized and there was a supply of can goods and cereals. The administrator will do shopping once they have their first admission. As for now they have one refrigerator but will be placing a second one in the garage. Medication will be centrally stored in a locked cabinet in the kitchen area. There is a drawer that has a key lock for sharp knives and scissors. The water temperature was checked with a non-touch thermometer that measured at 110 degrees Fahrenheit.

The backyard was observed with a patio canopy with seating and tables for residents use. The garage area has two steel locking cabinets that have the cleaning supplies and detergent. The laundry area is also in the garage area.

The smoke detectors and carbon monoxide detectors were checked for operation. First aid kit is complete with a 2020 first aid manual. A Fire extinguisher is located in the dining room area that is fully charged and maintained till October 2021.

The necessary posters were hung up in the common area such as Resident Rights, theft and loss policy, and Let us know poster. The ombudsman poster was missing since the administrator was informed, they would receive one after they were licensed.

The administrator stated he has complete staff file there and gave LPA his current administrator certificate which expires in July of 2021. LPA reminded administrator to make sure he submits his renewal immediately to avoid any delays.

Administrator stated he has already taken Comp III. The administrator was informed to submit a copy of the liability insurance once received. The department has already received an LIC610E. A plan of operation folder will be completed by administrator and placed in facility for reference. An updated LIC500 staff schedule shall be submitted to LPA for the file. The At this time LPA informed Administrator to follow through with an updated LIC500 staff schedule and to send a copy of his administrator certification.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angelica Arambulo	TELEPHONE: (818) 596-4358
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2021

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CHATSWORTH LIVING	FACILITY NUMBER: 197610159
	VISIT DATE: 04/22/2021

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The administrator was informed to make sure he is compliant with federal and state laws. Administrator was informed to make sure he registers to receives the Provider information notices and reviews them so he is aware of protocols and procedures. In addition administrator was informed to check with the California Department of Public Health regarding Covid 19 Protocol for residential facilities.

The facility is in compliance with Title 22 regulations at this time. The LPA will notify the Centralized Application Unit. Exit conference held and report was emailed to Applicant for signature. Once signed the original shall be mailed and emailed to LPA.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angelica Arambulo	TELEPHONE: (818) 596-4358
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2021

LIC809 (FAS) - (06/04)

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