197610298-1-12-2023-31-AS-JMAZ-CMZQCF-20230112110304

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610298
Report Date: 01/12/2023
Date Signed: 01/12/2023 11:03:51 AM

Document Has Been Signed on 01/12/2023 11:03 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:	LINDLEY RESIDENTIAL CARE		FACILITY NUMBER:	197610298
ADMINISTRATOR:	AVETISYAN, ARMENUHI		FACILITY TYPE:	740
ADDRESS:	18124 VINTAGE STREET		TELEPHONE:	(818) 983-2224
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY:	6	CENSUS: 0	DATE:	01/12/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Armenuhi Avetisyan		TIME COMPLETED:	11:10 AM

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On 01/12/22 Licensing Program Analyst (LPA) Joscelyn Martinez arrived at the facility to conduct a Pre-licensing visit. Upon arrival LPA met with Administrator Armenuhi Avetisyan and the purpose of the visit was explained. This is an application is for Residential Care Facility for Elderly. Facility has requested a total capacity of six residents (6) of which all need all will be ambulatory. This is a single-story home with three(3) bedrooms and three(3) bathrooms.

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 68 degrees F, which meet regulations. The air conditioner is operational. No firearms observed or will be maintained on the premises. Facility contains dual smoke alarm and carbon monoxide detector. Detectors were operational and tested at 10:20 a.m. The fire extinguisher was observed to be full with a purchase date of 12/16/22. Facility maintains a telephone landline that was tested and observed to be operational. Activities were observed in the living room area. Medications and files will be kept in a locked cabinet in the dinning area. First aid kit was observed and contained the proper items stated by regulations.

Kitchen Area: LPA observed the kitchen area to be in good repair and sanitary. LPA observed a seven-day supply of nonperishable and a two-day supply of perishable food. Sharps were observed to be locked and inaccessible to residents. Trash can contain a tight-fitting lid. Chemicals are locked and stored under the kitchen sink as well as in the garage area. The laundry area will not contain any chemicals. LPA observed plates and cups for resident’s use.

Bedrooms: Facility has three(3) bedrooms of which two will be shared and one private. All bedrooms were toured and were observed with the appropriate furniture and bedding. LPA observed additional bedding linens.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

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: LINDLEY RESIDENTIAL CARE	FACILITY NUMBER: 197610298
	VISIT DATE: 01/12/2023

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Bathrooms: Facility has three (3) bathrooms. 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 118.4 degrees F. LPA observed sufficient towels and wash cloths for residents.

Outside: This facility is the middle home of three homes located on the property. The front home has been licensed by CCLD as an RCFE and has it's own separate entrance. The third property is an Accessory Living Quarters to the first property and will not be part of the licensed homes. LPA observed appropriate outdoor furniture with a shaded area for residents. No bodies of water on the property. Facility has an attached garage that is only accessible through the outside of the home. Garage will be used for additional storage.

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.

Once component III is completed, 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.

Report signed and delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

LIC809 (FAS) - (06/04)

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