197610307-1-9-2024-31-AS-GSAO-CZBQCV-20240109110346

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610307
Report Date: 01/09/2024
Date Signed: 01/09/2024 11:04:02 AM

Document Has Been Signed on 01/09/2024 11:04 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	VILLA GRANADA ASSISTED LIVING		FACILITY NUMBER:	197610307
ADMINISTRATOR:	MUSHEGHYAN, ANAHIT		FACILITY TYPE:	740
ADDRESS:	17412 TILFORD CT		TELEPHONE:	(818) 282-4122
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	6	CENSUS: 4	DATE:	01/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Ruzanna Manukyan		TIME COMPLETED:	11:30 AM

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On 01/09/24, at 08:55 a.m., Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, annual visit. Upon arrival, LPA met with caregiver Tolkyn Bogumbayeva and disclosed the purpose of the visit. The designee administrator- Ruzanna Manukyan was called and arrived about ten (10) minutes later.

LPA asked for the census, resident, and staff rosters.

The facility tour started 9:45 a.m. Temperature of facility wall thermostat was observed at 70 degrees Fahrenheit. The facility has a signal system.

There is a backyard which has two (2) outdoor furniture tables for outdoor activities. There is no pool or garage. There are two storage houses in the backyard filled with extra mattresses, tools, and Christmas things. The washer and dryer is also located in the backyard. There is an extra refrigerator in the backyard with food.

Living and dining room furniture is accessible for four (4) residents. There is a television and enough seating for four (4) residents. Furniture was observed to be in good condition. There is no fireplace. There is smoke detectors and carbon monoxide detectors all over the house. The smoke detectors and carbon monoxide are hardwired and interconnected and were tested. They were functional.

Medications-LPA observed the medication cabinet to be in the kitchen area stored and locked inaccessible to residents.

809C-continued

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLA GRANADA ASSISTED LIVING	FACILITY NUMBER: 197610307
	VISIT DATE: 01/09/2024

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The first aid kit is stored in a cabinet area at the entrance of the facility along with extra PPE’s items.

Kitchen area was sufficiently stocked with seven (7) days of perishable and seven (7) days of non-perishable food. There is one refrigerator in the kitchen area. The cabinets have canned goods. Sharps are kept secured and locked in one of the cabinets on your left-hand side, under the kitchen sink there is toxins that are inaccessible to residents. There is one fire extinguisher located against the wall in the kitchen area fully charged and dated July 2023. There is one phone line located in the kitchen area.

Bedrooms: There are four (4) bedrooms. Two of the bedrooms is shared, but one is currently being used as a single, occupancy. There is another bedroom that is single, occupied. Another bedroom is currently vacant and there are two bathrooms. One of the bathrooms, is for staff use only that is locked and inaccessible to the residents. This bathroom has extra toxins and hygiene for the residents. There is one bathroom on your left-hand side of the entrance of the facility that can be used by staff and the residents. All four (4) bedrooms are properly furnished with proper lightning. The bathrooms have proper toiletry and grab bars. The bathroom temperature of the water is within regulations. It reads between 110-112.2 Fahrenheit.

Administrative: There is no annual fee that is due right now. The Insurance plan is updated, disaster plan, YES sign, administration certificate, licensee certificate, Infection control, Ombudsman, and Employee Schedule are against the wall at the entrance of the facility.

An exit interview was conducted, no citations were issued, and a copy of this report was given to the administrator.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

LIC809 (FAS) - (06/04)

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