197610159-5-2-2024-31-AS-HRAI-D4VTG9-20240502144245

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610159
Report Date: 05/02/2024
Date Signed: 05/02/2024 02:43:31 PM

Document Has Been Signed on 05/02/2024 02:43 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:	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: 4	DATE:	05/02/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Zhaneta Arshakyan, Administrator Designee		TIME COMPLETED:	03:15 PM

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At 11:50 AM, Licensing Program Analyst (LPA), Huma Rahimi conducted an unannounced annual inspection at the facility mentioned above. LPA was greeted by the staff, Nina who granted access to the facility. Administrator Designee Zhaneta Arshakyan, arrived shortly after and LPA explained the reason for the visit.

At 12:15 PM, LPA conducted a tour of the facility and the following was observed:

Kitchen: At approximately, 12:15 PM, LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum one (1) week and perishable for two (2) days at the facility. All knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents. There is a fire extinguisher by the kitchen and it was last purchased on 10/24/23.

Medications: At approximately, 12:18 PM, LPA observed medications are centrally stored and locked in the cabinet outside of the kitchen along with resident and staff files and inaccessible to residents in care. LPA also observed a First Aid Kit complete with the required items as per Title 22 Regulations.

Bedrooms: There are four (4) bedrooms designated for residents use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Auditory alarms were tested and observed to be operational. Staff bedroom is located by the kitchen.

Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024

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: CHATSWORTH LIVING	FACILITY NUMBER: 197610159
	VISIT DATE: 05/02/2024

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Bathrooms: At 12:30 PM, LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured at 111.5°F. LPA observed appropriate grab bar and non-skid mat. LPA observed appropriate hand washing signs posted in each bathroom. All trash cans in bathrooms had fitted lids to protect from cross contamination.

Common Areas: The facility maintains a comfortable temperature at 76°F. The living room and dining area appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility.

Outside areas: At approximately, 12:40 PM, LPA toured the outside area of the facility. LPA observed a clean covered patio and backyard furniture to accommodate the six (6) residents. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents. There are no bodies of water.

The garage: Laundry area is located by an attached garage and kept locked and inaccessible to residents. Extra PPE supplies and food storage was also observed. LPA observed an office area for the facility inaccessible to residents in care.

Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 12:55 PM, they were tested and observed to be operational.

Between 1:00 PM to 2:15 PM, LPA reviewed records of four (4) residents and two (2) staff. Resident and staff records appeared to be complete and updated.

Administrative: LPA collected Certificate of Liability Insurance and LIC500.

No citations issued during this visit. Exit interview conducted. Copy of report emailed to Licensee.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024

LIC809 (FAS) - (06/04)

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