197610353-3-13-2023-31-AS-SSTS-CPVSUV-20230313141146

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610353
Report Date: 03/13/2023
Date Signed: 03/13/2023 02:12:37 PM

Document Has Been Signed on 03/13/2023 02:12 PM - 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:	CACTUS FRONT HOMES LLC		FACILITY NUMBER:	197610353
ADMINISTRATOR:	NAZARYAN, ANTUAN		FACILITY TYPE:	740
ADDRESS:	10187 WEALTHA AVE		TELEPHONE:	(818) 292-2087
CITY:	SUN VALLEY	STATE: CA	ZIP CODE:	91352
CAPACITY:	6	CENSUS: 0	DATE:	03/13/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Antuan Nazaryan, Licensee/Applicant		TIME COMPLETED:	02:25 PM

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Licensing Program Analyst (LPA) Shira Stamps met with Antuan Nazaryan (Licensee/Applicant) for a Pre-licensing inspection at 11:00 am. Entrance interview conducted.

The home will serve six (6) residents, and is fire cleared for five(5) non ambulatory and one (1) bedridden. The facility has three (3) bedrooms and two (2) bathrooms. Staff will be awake at night. The physical plant was toured inside and out at 11:15 am.

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 at 68 degrees F, which meet regulations. The air conditioner is operational. No firearms observed or will be maintained on the premises. Medications will be kept centrally stored and locked in a cabinet located in the living room.

The dual smoke alarm and carbon monoxide detector were operational and tested at 11:40 am. Fire extinguisher located in the kitchen appears to be full and was inspected during fire clearance inspection.

Resident rooms: Two (2) rooms available will be shared. LPA observed rooms to have bedding sheets, pillowcase, blankets, mattress pads, which are in good condition. There is at least one chair, a nightstand, and sufficient lighting for each resident.

Window covering and window screens are in good repair for each room.

Residents will have sufficient amounts of supplies for personal hygiene products, which is provided by the Licensee.

CONTINUED...

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023

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: CACTUS FRONT HOMES LLC	FACILITY NUMBER: 197610353
	VISIT DATE: 03/13/2023

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Bathrooms: LPA toured resident bathrooms and checked to make sure bathrooms were clean and in good repair. The hot water temperature was tested at 11”38 and measured within regulation at 112.5. The Licensee provided the appropriate non-skid strips in each shower. Five (5) Trash cans with lids are needed in shared rooms to protect residents from cross contamination. Towels and washcloths will not be shared. The facility will service residents with dementia, and will need a signal system for four (4) exit doors.

Kitchen Area: LPA inspected kitchen equipment. The refrigerator was clean and in good operation. Dishes in good repair. Knives and sharp objects will be kept locked inaccessible in a draw. Cleaning supplies will be kept under the sink in the locked cabinet. The stove is clean and in good operation. LPA observed sufficient supply of 7 day non-perishable foods.

Outside: LPA toured the outside area. LPA did not observe a cover shaded area for residents, but Licensee provided receipt of purchase. No bodies of water. LPA observed a locked room/shed attached to the home accessed from the outside. The area is currently being used for storage and tools but will eventually become the staff office. The Licensee stated it will remain locked at all times.

Garage: The garage is accessed from outside with the laundry area. All chemicals and cleaning supplies are locked in a cabinet. All tools are locked in separate cabinets.

Files will be kept confidentially stored in the cabinet located in the living room and supplied to licensing staff upon request.

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.

Applicant/ Administrator has completed component III.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CACTUS FRONT HOMES LLC	FACILITY NUMBER: 197610353
	VISIT DATE: 03/13/2023

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The licensee will need to complete the following before the license is approved.

1. Trash cans with lids in the two (2) bathrooms and three (3) bedrooms to protect from cross contamination. Submit receipt for the trash can.

2. Outdoor seating with a covered shaded area. Submit receipt.

3. First Aid Manual approved by the American Red Cross. Submit receipt.

4. Signal Alarm on four (4) doors. Submit receipt and picture of installation.

The facility is ready for operation upon correction of requested items in this report, and final approval of the application. Submit items for correction no later Friday 3/17/2023.

Exit interview conducted.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023

LIC809 (FAS) - (06/04)

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