197610275-8-10-2022-31-AS-JMAZ-CH6PWV-20220810114119

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610275
Report Date: 08/10/2022
Date Signed: 08/10/2022 11:41:35 AM

Document Has Been Signed on 08/10/2022 11:41 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:	MY HOME FACILITY		FACILITY NUMBER:	197610275
ADMINISTRATOR:	MUSHEGHYAN, ANAHIT		FACILITY TYPE:	740
ADDRESS:	19837 SEPTO STREET		TELEPHONE:	(808) 707-8808
CITY:	CHATSWORTH	STATE: CA	ZIP CODE:	91311
CAPACITY:	6	CENSUS: 0	DATE:	08/10/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Anahit Musheghyan		TIME COMPLETED:	11:50 PM

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On 08/10/22 at 10:00 a.m Licensing Program Analyst (LPA) Joscelyn Martinez arrived at the facility to conduct an announced Pre-licensing inspection. Upon arrival LPA met with administrator Anahit Musheghyan. The facility will be licensed as a Residential Care Facility for the Elderly. Facility is a single-story house with five (5) bedrooms and three (3) bathrooms. Facility has been approved for a capacity for six (6) residents in which five (5) may be non-ambulatory and one (1) bedridden. Hospice waiver has been approved for six (6) residents.
The physical plant was toured inside and out at 10:05 a.m

Common Area: LPA observed the living room and furniture to be clean and in good repair. LPA observed the dining area to be clean and in good repair. The facility maintains a comfortable temperature at 78 degrees F, which meet regulations. The air conditioner is operational. No firearms observed or will be maintained on the premises. The smoke alarm and carbon monoxide detector were operational and tested at 10:20 a.m The fire extinguisher was observed to be full with a purchase date of 04/13/22. Facility maintains a telephone landline that was tested and observed to be operational. Activities were observed in the living room area.

Kitchen Area: LPA observed the kitchen area to be in good repair and sanitary. A start up amount of perishable and non-perishable foods were observed. Sharps were observed to be locked and inaccessible to residents. Trash can contain a tight fitting lid. Medication and files will be kept in a lock drawer in the kitchen. Chemicals and cleaning supplies will be kept locked under the sink area.

Bedrooms: Facility has five (5) bedrooms in which one will be a shared bedroom. Bedroom number one (1) will be designated for bedridden resident. All of the other rooms have been approved for non-ambulatory residents. All bedrooms were toured and were observed with the appropriate furniture and bedding. Night-lights were observed in residents’ room. The hallway lights will be kept on at night to prevent any falls.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

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: MY HOME FACILITY	FACILITY NUMBER: 197610275
	VISIT DATE: 08/10/2022

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Bathrooms: Facility has three (3) bathrooms of which one (1) will be designated for staff use. Bathrooms were toured and were observed to have trash cans with tight fitting lids. The showers contained grab bars and non-skid mats. Hot water was tested and measured at 105.1 degrees F. LPA observed sufficient towels and wash cloths for residents.

Garage: Facility has a separate laundry room that is connected to the garage. Laundry chemicals will be in a locked cabinet inside the laundry room. Garage door is accessible through the laundry area and will remain locked. Garage was toured. Garage area will be used as a storage area.

Outside: LPA observed appropriate outdoor furniture with a shaded area for residents. There is a body of water that will be kept locked and inaccessible to residents.

Pre-Licensing Self-Certification checklist was discussed with administrator. LPA 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. No deficiencies were observed.

Applicant/ Administrator has completed component III.

This report will be sent to Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when the license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

LIC809 (FAS) - (06/04)

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