197610209-11-3-2023-31-AS-MCAA-CX8NEN-20231103102413

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610209
Report Date: 11/03/2023
Date Signed: 11/03/2023 10:24:24 AM

Document Has Been Signed on 11/03/2023 10:24 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: 0	DATE:	11/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Eduard Hakobyan		TIME COMPLETED:	10:30 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with the administrator, Eduard Hakobyan and explained the reason for the visit. The facility is currently vacant. Although license is active, the licensee isn't operating at this time. Licensee is awaiting process of the Assisted Living Waiver (ALW) application. At approximately 09:15am, with the assistance of the administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are interconnected and battery operated. It is dual with the carbon monoxide detector. The fire extinguisher is brand new and located in the kitchen. Kitchen: The kitchen appliances and fixtures were functional. Because no residents at this time, licensee doesn't store any perishable and non-perishable food. Licensee advised will store a sufficient amount of perishable and non-perishable once they start operating. Bedrooms: There are four (4) bedrooms designated for residents' use. Rooms #1 an #4 are private. Rooms #2 and #3 are shared. All bedrooms were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are two(2) bathrooms. One designated for staff and one designated for residents. The bathroom designated for residents was properly supplied and had functional fixtures. Hot water temperature was measured at 120 degrees Fahrenheit. No cleaning supplies stored in the bathrooms Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2023

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: 11/03/2023

NARRATIVE

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Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. The outdoor area was free of hazards. The laundry area is located in the garage. The garage is also used extra storage space. Facility has a staff room/work station, where medications, staff and resident records will be stored. This room will be locked and inaccessible to clients.

Resident Files: No files to review at this time

Staff Files: No files to review at this time.

Medications: No medications and medication documents to review at this time.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023

LIC809 (FAS) - (06/04)

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