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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610314
Report Date: 11/17/2022
Date Signed: 11/17/2022 11:29:36 AM

Document Has Been Signed on 11/17/2022 11:29 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:PRESTIGE ASSISTED LIVING, INCFACILITY NUMBER:
197610314
ADMINISTRATOR:TOHOYAN, ANAHITFACILITY TYPE:
740
ADDRESS:8315 OSO AVENUETELEPHONE:
(747) 206-5192
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 6CENSUS: 0DATE:
11/17/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Anahit Tonoyan, Roza TonoyanTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Michael Cava conducted a Pre-Licensing Inspection with the applicant representative and administrator, Anahit Tonoyan and Roza Tonoyan. An Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on July 1, 2022. A fire clearance was approved on September 12, 2022 for five (5) non-ambulatory residents and one (1) bedridden resident, for a total capacity of six. The applicant is also requesting a hospice waiver to retain six (6) residents. The smoke alarms and carbon monoxide detector are hard wired and inter-connected. The facility has two new fire extinguishers that was purchased on September 7, 2022. One fire extinguisher is located in dining room/kitchen area, and the other at the hallway.

A tour of the physical plant was initiated at approximately 9:45am and the following was observed:

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven and sink. The Hot water delivered is measured at 116 degrees F. There were adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). Knives were observed locked in a kitchen drawer.

BEDROOMS: There are five (5) bedrooms designated for client use. Bedroom #1 and #2 are cleared to be shared rooms, with bedroom #1 having a bedridden fire clearance (per STD 850). Bedrooms #3, #4 and #5 are private rooms. The applicant furnished the resident bedrooms with beds, night stand, chairs, dresser, bedding and linen. The bedrooms have sufficient lighting and closet space.

BATHROOMS: The facility has three (3) bathrooms. Bedroom #1 has it's own bathroom with shower and tub. The other two bathrooms are located by the facility entrance, and at the hallway, by bedrooms #2, #3, #4, and #5. The bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured at 116 degrees.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
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: PRESTIGE ASSISTED LIVING, INC
FACILITY NUMBER: 197610314
VISIT DATE: 11/17/2022
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COMMON AREAS: These included the tv and activity room which were equipped with living room furniture, a television, tables and chairs. There is a fireplace with a screen and a glass slide. It is non-operational, with the key stored and inaccessible to residents. No fireplace tools or fixtures present. The dining area has a large dining room table to accommodate six (6). There were no visible immediate hazards.

LAUNDRY ROOM: The laundry room is located in the kitchen. It was observed with a locked sliding door to make it inaccessible to the residents. The washer/dryer are brand new.

MEDICATIONS: The medication cart is located adjacent to the kitchen, at the staff work station. It has a locking mechanism.

OFFICE/STAFF WORKSTATION: Staff workstation is located by the tv/activity room. Resident and personnel files will be maintained in a locked filing cabinet there, alongside the medication cart.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. All entry and exit doors have a functional auditory alert when the doors open. The backyard of the facility has a patio and backyard furniture to accommodate the six (6) residents. The facility backyard has sufficient yard space. There is a swimming pool that is fenced all around with a gate that will be kept locked at all times. The fence surrounding the swimming pool is approximately 5 feet high all around its parameters. You will need a key to unlock the padlock to gain entry to the swimming pool as it is kept locked at all times.

Pursuant to Title 22, Division 6 of the CA Code of Regulations, the facility's physical environment appears to be compliant and ready for licensure. CAB will be advised and a copy of this report provided.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
LIC809 (FAS) - (06/04)
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