197610345-3-20-2023-31-AS-TAGD-CQ4PBY-20230320111106

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610345
Report Date: 03/20/2023
Date Signed: 03/20/2023 11:11:20 AM

Document Has Been Signed on 03/20/2023 11:11 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	HILDA ASSISTED LIVING		FACILITY NUMBER:	197610345
ADMINISTRATOR:	YEGEYAN, MARY		FACILITY TYPE:	740
ADDRESS:	17179 SAN JOSE STREET		TELEPHONE:	(818) 403-1803
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	6	CENSUS: 0	DATE:	03/20/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:38 AM
MET WITH:	Nazar Yegeyan & Mary Yegeyan.		TIME COMPLETED:	11:15 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Troy Agard conducted an announced visit to the above facility for the purpose of a pre-licensing evaluation. LPA met with Administrator and Licensee, Mary and Nazar Yegeyan and explained the purpose of the visit. During the inspection LPA toured the inside and outside of the facility and verified the address of the location. An application was submitted to Community Care Licensing Division (CCLD) on 09/01/2022 for a pre-licensing for a Residential Facility for the Elderly (RCFE). The total requested capacity is for 6 (six) residents. Facility has a fire clearance dated on 02/22/2023 for 5 (five) non- ambulatory and 1 (one) bedridden for a total of 6 (six) residents. Structure: The facility is located in a residential neighborhood. It is two-stories in height, but the residential facility will only be on the first floor of the house. The upper level (2^nd level) of the facility is inaccessible. The facility has 4 (four) resident-bedrooms in total. Upon entry, straight ahead is the sitting / living area, open concept kitchen and dining room. Immediately to the right is bedroom 1 (one) and 2 (two). Bedroom 1 (one) or 2 (two) have been cleared for a bedridden resident. Immediately to the right is a hallway that leads to bedroom 3 (three), 4 (four), bathroom and laundry nook. Off of the kitchen is an enclosed patio that is gated with a high white fence. There are exits (egress) attached to rooms 1, 2 and 3. Rooms 1 and 2 exit lead to the front entrance. Room 3 leads to the patio. Adjacent is a driveway and directly behind the facility is additional land. LPA did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility. Bedrooms: Bedrooms have a chair, nightstand, over-head lighting, dressers and/or closets. The facility provides furnished rooms. The closets and drawers comply with the requirement of 8 cubic feet of space. Bedrooms 1 (one) and 2 (two) are private rooms and rooms 3 (three) and 4 (four) are shared. cont on 809C

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: 818-421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023

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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HILDA ASSISTED LIVING	FACILITY NUMBER: 197610345
	VISIT DATE: 03/20/2023

NARRATIVE

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Office: The facility does not have a private administrative office. Staff records and resident records will be held on site in the facility inside a locked cabinet.

Bathrooms: Facility has 2 bathrooms. Bathrooms were observed to have a working toilet, and wash basin. All stand up showers were observed in working order with secured grab bars. Water temperature tested at 111.8 degrees Fahrenheit

Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen; sheets, pillowcases, hand towels, bath towels and wash cloths are available to residents. The residents have access to hygiene supplies should they need.

Emergency Phone Numbers, Exit Plan & Menu: The telephone, which is a land line, was called by LPA and is operational. Emergency Disaster Plan and "See something, say something, Let Us Know" was observed posted on a living room bulletin board. LPA observed one fully charged fire extinguisher in the kitchen area.

Food Service: Dishes, cups and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked cabinet in a lockbox. Food supply was adequately stored in kitchen refrigerator, cabinets and pantry.

Smoke Detectors: Facility is equipped with dual smoke and carbon monoxide detectors. Which are hardwired and interconnected throughout the facility. Detectors are not connected to notify the fire department in the event of a fire. Staff are required to call in the event of an emergency.

Appliances: Stove burners, oven, microwave, washer, and dryer are in working order. There is a large refrigerator in the kitchen. Refrigerator and freezer are at the correct temperature for food storage.

Toxins: Locked/stored in kitchen cabinet.

Medications, First-Aid Kit & Book: Area for medication storage is in the kitchen area. First aid kit was inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze. First aid and medications are available for staff use but inaccessible to residents.
cont on 809C

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: 818-421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023

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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HILDA ASSISTED LIVING	FACILITY NUMBER: 197610345
	VISIT DATE: 03/20/2023

NARRATIVE

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Clients & Staff Files: Records for staff and residents are stored on site.

Reading Material, Games, Equipment & Materials: The facility has recreational materials for the resident’s use including but not limited to books, arts and crafts, etc.

Pool/Jacuzzi & Pets: LPA did not observe a pool, jacuzzi or pet on facility grounds.

Fire clearance: Fire Clearance was approved on 02/22/2023 for 5 (five) non- ambulatory and 1 (one) bedridden for a total of 6 (six) residents. Per inspection, all 1^st floor rooms are approved for non-ambulatory and bedridden residents. LPA did not observe pad locks or other mechanisms which may be obstructions for safe and quick egress during an emergency on front and back exits.

Component III: Conducted at the Pre-Licensing visit, on 03/20/2023 at HILDA ASSISTED LIVING. Information was provided about how to operate the facility within substantial compliance.

During the pre-licensing inspection, no items were observed which do not comply with applicable laws and regulations; no items require a follow up inspection for verification of correction.

Pre-Licensing is complete, and this facility has no deficiencies.

An exit interview was conducted, and a copy of this report has been furnished to the applicant.

Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to the applicant.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: 818-421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023

LIC809 (FAS) - (06/04)

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