197610248-1-9-2023-31-AS-MRUZ-CMWQPD-20230109112033

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610248
Report Date: 01/09/2023
Date Signed: 01/09/2023 11:21:05 AM

Document Has Been Signed on 01/09/2023 11:21 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:	VELVET CARE		FACILITY NUMBER:	197610248
ADMINISTRATOR:	PAROYAN, NAIRA		FACILITY TYPE:	740
ADDRESS:	15731 LEMARSH ST.		TELEPHONE:	(818) 891-9186
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY:	6	CENSUS: 5	DATE:	01/09/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Naira Paroyan - Licensee		TIME COMPLETED:	11:25 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	On 1/9/2022, Licensing Program Analysts (LPA) Melissa Ruiz conducted an announced Pre-Licensing visit to this facility and met with applicant Naira Paroyan. This is a Change of Ownership Application from facility license number #197610143 to #197610248. A fire Clearance dated 2/9/2022 was received for six (6) residents, of which four (4) could be non-ambulatory residents, and one (1) bedridden in Room #2 or #4. Facility has a hospice waiver for six (6) residents. The purpose of today’s visit is to inspect the facility to ensure that it maintains compliance under California Code of Regulations, Title 22, Division 6. Today’s site visit consisted of LPA touring the physical plant inside and outside and observed the following: The facility has separate carbon monoxide and smoke alarm system. There are various fire extinguishers, with a date of purchase of 5/11/22. There is a functioning telephone on the premises. An emergency exit plan/sketch is posted on the hallway wall with other posting requirements. There are (4) resident bedrooms, two of which are (2) private and two (2) are shared. One (1) additional bedroom is designated for staff use. Resident bedrooms were observed to be appropriately furnished. The common areas (living room, kitchen and dining areas) were appropriately furnished, and lighting was adequate. The living room has a television and comfortable furniture. Resident and staff records are stored in a locked cabinet in the designated office area. Medications are centrally stored in a locked kitchen cabinet. The first aid kit is readily available. There are three (3) bathrooms in the facility. One (1) bathroom is designated for staff use only and the two (2) common bathrooms have non-skid mats and appropriate grab bars. Trash cans were observed to have closed tight fitting lids. (CONT. on LIC809-C)

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2023

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: VELVET CARE	FACILITY NUMBER: 197610248
	VISIT DATE: 01/09/2023

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
26
27
28
29
30
31
32

The kitchen knives are stored in a locked drawer. The kitchen cleaning supplies are stored in a locked cabinet under the kitchen sink. Laundry detergents, cleaning supplies and other toxins are stored in the garage. The laundry area is in the garage. The necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on all doors and locked areas for centrally stored medications. Facility appears to be clean and in good repair. Appliances in the kitchen appeared to be functional.

There is a sitting area in the backyard for residents to conduct outdoor activities. The backyard is fenced. The garage is attached to the house and is kept locked and inaccessible to residents. The garage is currently being used as a laundry area, emergency and perishable food and other supplies storage such as PPE. There is no body of water in the facility.

Component III was conducted with applicant.

No deficiencies issued with this report. This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. Exit interview was conducted with Licensee Representative Naira Paroyan. A copy of this report was signed and delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2