197610162-8-3-2021-31-AS-TDON-C5JKE7-20210803074952

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610162
Report Date: 07/30/2021
Date Signed: 08/03/2021 07:50:05 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814

FACILITY NAME:	LOVE & CARE SENIOR LIVING, INC.		FACILITY NUMBER:	197610162
ADMINISTRATOR:	LYSENKO, OLENA		FACILITY TYPE:	740
ADDRESS:	17710 MARTHA STREET		TELEPHONE:	(818) 585-0063
CITY:	ENCINO	STATE: CA	ZIP CODE:	91315
CAPACITY:	6	CENSUS:	DATE:	07/30/2021
TYPE OF VISIT:	Office	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Olena Lysenko and Davit Hakobyan		TIME COMPLETED:	10:30 AM

NARRATIVE

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COMP II by CAB successfully completed

Facility Type: RCFE
Application Type: LLC
Capacity: 6
Census (if any clients in care): NO
Method: Telephone at CAB
COMP II Participants: Olena Lysenko (Applicant) and Davit Hakobyan (Administrator)

Applicant/Administrator participated in COMP II at CAB via telephone with analyst at CAB. Identification of the Applicant and Administrator was verified by providing California Driver License number. During COMP II, Applicant and Administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and Administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:

1. Facility operation: License type, client/resident populations, and program

2. Staff qualifications and responsibilities
3. Applicant and Administrator qualifications
4. Program policy: Abuse, admission agreement, medication management, reporting
incidents to CCL, restricted & prohibited conditions
5. Grievances, Complaints, Community resources
6. Physical plant, food service
Application document review and technical assistance: Criminal record clearance,
Health screening, Fire clearance, First Aid/CPR certificate, Administrator
certificate, Financial verification, Pre-licensing inspection, Compliance history,
Control of property

SUPERVISOR'S NAME: Julia Kim	TELEPHONE: (916) 651-7848
LICENSING EVALUATOR NAME: Thai Doan	TELEPHONE: (916) 651-1057
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021

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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