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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610176
Report Date: 01/19/2022
Date Signed: 01/19/2022 01:13:25 PM

Document Has Been Signed on 01/19/2022 01:13 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ESSENTIAL CARE ASSISTED LIVINGFACILITY NUMBER:
197610176
ADMINISTRATOR:KHACHATRYAN, VERZHINEFACILITY TYPE:
740
ADDRESS:3132 WAVERLY DR.TELEPHONE:
(818) 284-7607
CITY:LOS ANGELESSTATE: CAZIP CODE:
90027
CAPACITY: 6CENSUS: 0DATE:
01/19/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Verzhine KhachatryanTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) LaQueena Lacy conducted an announced Pre-Licensing visit to this facility
and met with Administrator Verzhine Khachatryan. Fire Clearance dated 04/30/2021 was received for five (5)
non-ambulatory residents and one (1) bedridden.

Entrance Interview conducted with the Administrator and explained the purpose of today’s visit, is to inspect the facility to ensure that the facility is in compliance with rules and regulations under California Code of
Regulations, Title 22, Division 6.

Today's site visit consisted of the LPA touring the physical plant at 10:30am inside and outside the
following was observed: The facility has one main entrance being used, there are required Covid-19
prevention signage (hand washing, coughing etiquette, social distancing) posted. The PPE screening is
conducted upon entrance at the front door. Sufficient PPE, hand sanitizer, gloves, mask, and sign in sheet
and thermometer is readily kept on the table near the entrance, located at the front door at the time of visit.
The facility is a single-story home. It has four (04) bedrooms, two (02) bathrooms. All exit doors
observed to have auditory alarms attached. At 10:35am the kitchen was observed to be clean and clear form
debris, appliances were observed to be in good repair and functioning. The facility currently does not
have any residents. At 10:38am LPA observed sharps to be locked and stored in a cabinet drawer next to the stove. At 10:46am LPA observed the Medications cupboard locked in the kitchen storing the First Aid Kit, Manual, and additional first aid supplies (alcohol, peroxide, cotton balls etc.).

At 10:58am all bedrooms were observed to be clean and appropriately furnished and equipped with adequate lighting. Extra linens, comforters, hand, and bath towels are stored in the residents’ room on a shelf in the closet.
Continued on LIC809C

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: LaQueena Lacy
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: ESSENTIAL CARE ASSISTED LIVING
FACILITY NUMBER: 197610176
VISIT DATE: 01/19/2022
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At 11:06am all bathrooms were observed to have non-skid mats and appropriate grab bars installed and all
trash cans contain lids. At 11:15am hot water was tested in the common bathrooms and measured in range
of 108.2 – 118.3 degrees F. The facility has a working telephone on premises. The emergency exit plan/sketch is posted on the living room wall near the entrance with other posting requirements. At 11:27am the common areas (living room and dining areas) were appropriately furnished and lighting is adequate. The living room has comfortable furniture for seating which was observed to be in good repair. The facility has a fireplace in the living room that will not be used and has a screen covering preventing access. The facility has central heating and air conditioning, LPA observed the facility to be a comfortable temperature of 72 degrees F.

AT 11:36am LPA observed an additional building on the property, which will be used as a recreational room for residents. The space is currently being used as a storage room inaccessible to residents. LPA observed the locked laundry room at 11:39am attached to the outside recreation building, storing laundry supplies, cleaning supplies, and toxins. The laundry space observed to be clean and clear from obstruction. At 11:46am the backyard and surrounding area of the facility was observed to be clean and clear from debris and obstruction. The back yard is enclosed with a gated fence and a shaded area for table and
chairs underneath the covering of the recreation building. At 11:54am LPA observed the swimming pool enclosed in an entry gate measured at 5ft 3in, the surrounding gate from the exit of room number (2) is on a ramp measured 3ft, and the gate on the ramp measured 3ft 6in. At 12:00pm LPA also observed an additional shed storing paint supplies and construction supplies, and a detached garage behind the house being used also as a storage. At 12:04pm LPA observed the front yard, clean and clear from obstruction.
The fire extinguisher located on the wall near the kitchen and dining room service dated 04/22/2021. At 12:08am the facility smoke/carbon monoxide alarms were tested and observed to be hard wired and interconnected, operational, and functioning properly. The facility appears to be clean and in good repair.

Component III was conducted with the licensee.

Facility is not in compliance with Title 22 Regulations at this time. LPA will contact Administrator for a return date to ensure compliance with Title 22 Regulation.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: LaQueena Lacy
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022
LIC809 (FAS) - (06/04)
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