197610314-1-7-2025-31-AS-PKHN-DCPR3N-20250107114010

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610314
Report Date: 12/11/2024
Date Signed: 01/07/2025 11:41:00 AM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/07/2025 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	PRESTIGE ASSISTED LIVING, INC		FACILITY NUMBER:	197610314
ADMINISTRATOR/ DIRECTOR:	RIMA AGARONYAN		FACILITY TYPE:	740
ADDRESS:	8315 OSO AVENUE		TELEPHONE:	(747) 206-5192
CITY:	WINNETKA	STATE: CA	ZIP CODE:	91306
CAPACITY: 6		CENSUS: 3	DATE:	12/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Rima Agaronyan - Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:45 PM

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On 12/11/2024 at 9:30am Licensing Program Analyst (LPA) Perchui Milena Khurshudyan arrived at this facility to conduct a Required Annual Inspection. LPA was greeted by the Administrator Rima Agaronyan who granted access to the facility. LPA Khurshudyan reviewed the required postings on a wall in the living room area. The inspection tool was used to complete the visit.

At 10:00am. LPA along with Rima Agaronyan – Administrator began a physical plant tour of the facility and the following was observed by the LPA: This is a single-story building with five (05) bedrooms, three (03) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for six (6) residents of which six (6) may be non-ambulatory, one (1) bedridden for Room #1. Facility has Hospice waiver for six (6) residents.

Kitchen: LPA observed a seven day supply of non-perishable food and a two day supply of perishable foods; properly stored and labeled. Facility stores knives, sharps, and chemicals in a separate locked cabinets in the kitchen. LPA observed one (1) fire extinguisher located by the kitchen fully charged with a serviced date of 9/7/2024. A weekly menu was also available posted in the kitchen.

Common Areas: These include the living areas and the dining areas. LPA observed dining, living areas clean and clear of clutter with furniture in good repair. Dining and living room furniture sits the capacity of the facility. Walls, floors, windows, screens, ceiling fans, and blinds were clean and in good repair. At 11:45pm. LPA measured the room temperature to be 74 degrees Fahrenheit. There is an adequate supply of fresh linens ready to use in each residents’ bedrooms.

LPA observed a gated fireplace in the living room and got informed that the fireplace is non operational. There was a television and various activities, games, board games stored inside the cabinet located in the living room.

Continue on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024

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: PRESTIGE ASSISTED LIVING, INC	FACILITY NUMBER: 197610314
	VISIT DATE: 12/11/2024

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Bedrooms: There are five (5) bedrooms all designated for residents’ use: four (4) for private use and one (1) shared room. LPA observed bedrooms to be properly furnished with beds, linens, night stand, a chair, drawers, closet, and adequate lighting. All bedrooms appeared organized and clean.

Bathroom: There are three (3) bathrooms in the facility of which two (2) are designated for residents’ use and one (1) for staff members only. The bathrooms contained hand soap, paper towels, toilet paper and trash bins with lids. Hot water temperature was taken in all bathrooms at approximately 12:00pm. and measured 113.9 degrees Fahrenheit. LPA also observed required signs on the bathroom walls, grab bars near the toilet and shower, and a non-skid mat in the shower.

Smoke and Carbon Monoxide Detectors: The smoke and carbon monoxide detectors were tested by a staff at 12:35pm and were observed operational.

Laundry Room – Laundry machines, chemicals and laundry detergents are placed in the separate locked closet by the kitchen area.

Garage: At 12: 55pm LPA checked the garage and observed disinfectants, laundry detergents and hygiene supplies properly stored on the shelves. Also in the garage were extra emergency supplies of food and water, PPE supplies, medical equipment. Second refrigerator was also placed in the garage with additional fresh food supplies.

Backyard: LPA observed all emergency exit paths were free from obstructions. Exit gates were unlocked with self-closing latches. The patio area has appropriate outdoor furniture for residents, nice green area with two trees. There is a pool in the backyard which was observed to be properly fenced and locked.

Staff/Client File review: At 1:00pm-2:30pm. LPA conducted records review for three (3) out of three (3) staff files to insure compliance with licensing forms, and three (3) out three (3) residents records were reviewed to insure they are complete and updated. All files observed to be in compliance.

Continue on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: PRESTIGE ASSISTED LIVING, INC	FACILITY NUMBER: 197610314
	VISIT DATE: 12/11/2024

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Medications: At approximately 1:15pm. LPA reviewed Centrally Stored Medication Destruction Records for proper documentation. Facility also maintains Medical Administration Records (MAR). LPA observed centrally stored medication, and First Aid kit locked in the cabinet located in the living room and inaccessible to residents in care. LPA observed First-aid kit is complete and has new manual. Potentially dangerous items are kept inaccessible to residents in care. Facility operates with two (2) shifts and has two (2) staff members for each shift including an awake caregiver at nights. LPA observed emergency signals were on and operational on all exit doors.

An emergency exit plan/sketch is posted on the hallway wall along with other posting requirements.
LPA collected LIC500, LIC9020, and copy of Liability Insurance Certificate.

No deficiency cited on today’s visit. Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024

LIC809 (FAS) - (06/04)

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