197610264-6-27-2022-31-AS-TSMH-CFSVFR-20220627162422

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610264
Report Date: 06/27/2022
Date Signed: 06/27/2022 04:24:31 PM

Document Has Been Signed on 06/27/2022 04:24 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:	DREAM CARE FACILITY		FACILITY NUMBER:	197610264
ADMINISTRATOR:	GHOSALMYAN, GEVORG		FACILITY TYPE:	740
ADDRESS:	9849 CANEDO AVENUE		TELEPHONE:	(947) 777-0770
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY:	6	CENSUS:	DATE:	06/27/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Gevorg Ghosalmyan		TIME COMPLETED:	04:35 PM

NARRATIVE

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At 9:05 am Licensing Program Analyst (LPA) Tihesha “Lynn” Smith conducted an announced pre-licensing visit with administrator Gervog Ghosalmyan. The facility has a capacity of six (6). Application was received for six (6) total residents, five (5) ambulatory and one (1) may be bedridden.

Purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with the rules and regulations of California Code of Regulations, Title 22, Division 6. The facility is a single-story building.

Today's visit consisted of LPA touring the physical plant inside and outside and observed the following at 10:15 am:

Hot water was tested in the bathrooms and measured at approximately 111.2- 117.5°F. There is a functioning telephone/landline on the premises. An emergency exit plan/sketch is posted near each entrance/exit wall with other posting requirements.

There are five (5) bedrooms, four (4) private and one (1) shared. Resident bedroom #4 set up as show room was observed to be appropriately furnished with a bed, nightstand, lamp, dresser, linens, and television. There is a small room/closet near bedroom #5 designated as Employee only and will be used only as employee storage.

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.

The administrator work area is located in the living room. Resident and staff records will be locked in a lower cabinet in administrators’ work area. Medications will be stored in a locked cabinet in the kitchen. Emergency food supplies and water to be store in kitchen cabinet under medication cabinet and in garage. The first aid kit is readily available on kitchen counter near dining room door. There are four (4) bathrooms in the facility.

(Cont on 809C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022

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: DREAM CARE FACILITY	FACILITY NUMBER: 197610264
	VISIT DATE: 06/27/2022

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(Cont. from 809)

All bathrooms have non-skid mats, trash cans with lids and functional grab bars. The sharps are stored and locked drawer in kitchen to the right of the stove. Kitchen cleaning supplies, laundry detergents, and other toxins are stored in lower cabinets to the right of dishwasher. The facility has a variety of adequate perishable and non-perishable food supply. The necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on all entry/exit doors and locked areas for centrally stored medications. Appliances in the kitchen appeared to be functional. Facility appears to be clean and in good repair. The garage is attached to the house. Laundry room is located in garage with entry to garage accessible through kitchen and will remain locked at all times. The washer and dryer observed to be in good repair. There is a pool located in the facility observed to be enclosed by a fenced and locked.

There is a covered patio area in the back for residents to conduct outdoor activities. The backyard is fenced.

The fire extinguisher is located in the dining room, observed to be fully charged and was purchased on 04/13/2022. Dual Smoke and Carbon Monoxide detectors were observed in the facility, tested, and observed to be operational at approximately 1:30 pm.

Component III was conducted with the administrator.

Applicant agrees that all other bedrooms (#1,2, 3, and 5) will be furnished appropriately and the wardrobe/closet for bedroom #5 will be assembled. Applicant agrees to make the forementioned corrections and provide proof of corrections via photos and/or video to LPA Smith by July 8^th, 2022.

Facility is in compliance with Title 22 Regulations at this time. 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 and a copy of this report was provided.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022

LIC809 (FAS) - (06/04)

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