197610209-2-17-2022-31-AS-JMAZ-CBQR87-20220217114728

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610209
Report Date: 02/17/2022
Date Signed: 02/17/2022 11:47:32 AM

Document Has Been Signed on 02/17/2022 11:47 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:	SUNSHINE SENIOR LIVING		FACILITY NUMBER:	197610209
ADMINISTRATOR:	HAKOBYAN, EDUARD		FACILITY TYPE:	740
ADDRESS:	15955 KALISHER STREET		TELEPHONE:	(747) 333-1100
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	6	CENSUS:	DATE:	02/17/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Administrator Eduard Hakobyan		TIME COMPLETED:	12:00 PM

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Licensing Program Analysts (LPAs) Joscelyn Martinez and Shira Stamps met with Eduard Hakobyn(Licensee/Applicant) for a Pre-licensing inspection at 10:00 A.M. This is a new licensee who will be operating a capacity of six (6) Residential Facility Care for the Elderly. The facility is a single story house and has four (4) bedrooms and two (2) bathrooms of which all bedrooms will be used for residents and two (2) bathrooms will be used for residents. Bathroom adjacent to room four (4) will be used for staff use.

The physical plant was toured inside and out at 10:10 am.

Common Area: LPAs observed the living room furniture to be clean and in good repair. LPAs observed the dining area to be clean and in good repair. The facility maintains a comfortable temperature at 69 degrees F, which meet regulations. The air conditioner is operational. No firearms observed or will be maintained on the premises.

Files will be kept confidentially stored in a locked cabinet located in the staff/office room and supplied to licensing staff upon request.

Resident rooms: Two (2) rooms will be shared and two (2) rooms will be private. LPAs observed rooms to have bedding sheets, pillowcase, blankets, which are in good condition. LPAs advise Administrator to purchase mattress pads. There is at least one chair, a nightstand, and sufficient lighting for each client. The mattresses and bedsprings were also checked for condition. Trash cans were observed not having tight fitting lids.

Window screens are in good repair but there are no window coverings. LPAs advised Administrator to purchase window covering that are non-see through.

Bathrooms: LPAs toured resident bathrooms and checked to make sure bathrooms were clean and in good repair. The hot water temperature measured within regulations at 115.6 degrees F. The showers have non-slip bathmats and grab bars. Trash cans with lids were in the restroom to protect consumers from cross contamination. Towels and washcloths will not be shared.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022

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: SUNSHINE SENIOR LIVING	FACILITY NUMBER: 197610209
	VISIT DATE: 02/17/2022

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Kitchen Area: LPAs inspected the kitchen equipment. The refrigerator was clean and in good operation. Dishes in good repair. Cleaning supplies will be kept locked inaccessible in the garage. Fire extinguisher was observed but did not have a tag. Administrator stated he purchased it a month ago and will send a copy of the receipt. Medications, knives, and sharp objects will be kept centrally stored and locked in a cabinet located in the kitchen. Stove and refrigerator are clean and in good operation. LPAs observed a startup supply of non-perishable and perishable foods.Outside: At 10:30 am, LPAs toured the outside area. LPAs observed a covered shaded area for clients. The facility has no bodies of water on the premises. Garage: The garage is attached to the facility. It will be used for additional storage and a laundry room. LPAs discussed preplacement, staffing, training, customer service, inspection authority, reporting requirements (mandated reporter), records, citations, criminal record clearance, civil penalties, labor law, activities, expectation is to follow all rules and regulations.

Things to do:

1. Purchase four (4) trash cans with tight fitting lids for all bedrooms.

2. Purchase and install window coverings for all bedrooms and bathrooms.

3. Purchase six (6) mattress pads for all beds and remove plastic coverings on mattresses and box springs.

4. Replace batteries for egress systems in bedroom number three (3)

5. Provide receipt for fire extinguisher.

6. Install plate covering in dining room area outlet

7. Install a single action lock in the kitchen exit.

8. Post Ombudsman and Community Care Licensing poster on main entrance wall. (20”x26’)

9. Administrator will come up with a plan on how he will lock and utilize storage area in garage.

10. Purchase thermometer, band aids, and gauze for first aid kit.

11. Send picture of installed phone for land line use.

12 Provide an updated LIC 200

Component III was conducted with the administrator.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022

LIC809 (FAS) - (06/04)

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