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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610171
Report Date: 08/02/2021
Date Signed: 08/02/2021 02:07:45 PM

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:HEART TO HEART SENIOR LIVINGFACILITY NUMBER:
197610171
ADMINISTRATOR:YEBEYAN, VERONIKAFACILITY TYPE:
740
ADDRESS:9330 ALDEA AVETELEPHONE:
(818) 731-6160
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY:6CENSUS: 0DATE:
08/02/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Veronika Yebeyan, AdministratorTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an announced Pre-Licensing visit to this facility and met with applicant Veronika Yebeyan, Administrator. Currently there are no residents in care. Visit was conducted on 8/02/2021. Component three was also conducted on 8/02/2021.
LPA Valenzuela conducted a tour of the physical plant with the applicant. Both the inside and outside of the facility were inspected. LPA inspected the facility for fire safety, personal accommodations and services, medication procedures, and food service. Facility has 6 bedrooms, four (04) rooms are private rooms and one (01) room is shared. Fire clearance is approved for six (06) non-ambulatory and six (06) bedridden residents. There are four (04) bathrooms. Three (03) bathrooms have the required grab bars for showers and toilets and one bathroom is for staff and visitors. LPA observed bedrooms and bathrooms to be clean. Bedrooms had appropriate linens on the beds, appropriate window coverings with screens, and appropriate furniture. Hot water was observed by LPA and administrator at 113.4 degrees F. The facility smoke alarm system and carbon monoxide are operable. Medications will be locked in kitchen cabinets, chemicals are stored underneath the kitchen sink which is locked and knives are in locked kitchen drawers. Emergency telephone numbers are posted in the entrance wall along with other required posters. There is a body of water on the premises. It is a locked gated swimming pool. There is a working telephone as well.
LPA toured all common areas. LPA observed the home to be clean and furniture to be in good condition. LPA did not observe any obstructions throughout the facility. Files were observed to be locked in a file cabinet in the kitchen. The patio had a covered area for outdoor sitting and activities.

Exit interview conducted and a copy of the report was provided. LPA will notify Centralized Application Unit regarding the component three being complete along with the pre-licensing visit being complete.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2021
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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