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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610159
Report Date: 04/05/2022
Date Signed: 04/11/2022 09:08:23 AM


Document Has Been Signed on 04/11/2022 09:08 AM - 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:CHATSWORTH LIVINGFACILITY NUMBER:
197610159
ADMINISTRATOR:TOUPHANIAN, ABRAHAMFACILITY TYPE:
740
ADDRESS:20453 MAYALL STREETTELEPHONE:
(818) 590-6793
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:6CENSUS: 1DATE:
04/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Abraham Touphanian TIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Joscelyn Martinez conducted an unannounced annual inspection. Upon arrival LPA met with staff and later met with Administrator Abraham Touphanian. The purpose of the visit was explained.

At 10:00 a.m. LPA conducted a physical tour of the facility. Infection Control: Covid-19 infection control signage were observed outside of the facility. Proper signage was also observed inside in the common areas. Upon entrance, staff took LPA’s temperature and was asked to sign-in the visitor’s log. Facility has sufficient PPE supplies for more than 30 days. Food Inspection: LPA Martinez observed there was sufficient stock of one-week non-perishable foods and two-day perishable foods. Sharps and medications are centrally stored in a locked area Smoke detectors/carbon monoxide are located throughout the facility and are hardwired. Smoke detectors and carbon monoxide detectors were tested at 11:10 a.m. and appear to be functional. Fire extinguisher has a purchase date of 10/24/2021. Common Areas: All common areas were observed to be clean and properly furnished. Facility maintains a comfortable temperature of 68.0 F. Residents Rooms: There are four (4) bedrooms all designated for resident use. All the four (4) bedrooms were toured and appear to be clean and properly furnished. LPA observed additional bedding and linens sufficient for all of the residents. Bathrooms: There are two (2) bathrooms in the facility. LPA observed all bathrooms to have grab bars and non-skid mats. The hot water was tested and measured at 115.6 F.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2022
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: CHATSWORTH LIVING
FACILITY NUMBER: 197610159
VISIT DATE: 04/05/2022
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Garage: There is an attached garage that is being used for additional storage and laundry area. Garage is locked and inaccessible to residents. Outside areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water.

No deficiencies cited at this time. Exit interview conducted. Report signed and delivered.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022
LIC809 (FAS) - (06/04)
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