197610371-3-16-2023-31-AS-SSTS-CPYRJ4-20230316130318

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610371
Report Date: 03/16/2023
Date Signed: 03/16/2023 01:04:34 PM

Document Has Been Signed on 03/16/2023 01:04 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:	A & A ASSISTED LIVING HOMES		FACILITY NUMBER:	197610371
ADMINISTRATOR:	DAVTYAN, ARMENUHI		FACILITY TYPE:	740
ADDRESS:	9857 LA TUNA CANYON ROAD		TELEPHONE:	(818) 726-0019
CITY:	SUN VALLEY	STATE: CA	ZIP CODE:	91352
CAPACITY:	6	CENSUS: 0	DATE:	03/16/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Armenuhi Davtyan, Licensee		TIME COMPLETED:	01:15 PM

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Licensing Program Analyst (LPA) Shira Stamps met with Armenuhi Davtyan (Licensee/Applicant) for a Pre-licensing inspection at 10:20 am.

Entrance interview conducted.

The facility has five (5) bedrooms and two (2) bathrooms designated for a capacity of six (6) residents. One (1) bedroom is designated for staff/office only and will remain locked at all times. Staff will be awake at night. The physical plant was toured inside and out at 10:45am.

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 71 degrees F, which meet regulations. The air conditioner is operational. No firearms observed or will be maintained on the premises.

The dual smoke alarm and carbon monoxide detector were operational and tested at 11:15 am. Fire extinguishers appear to be full and serviced on 03/202.

Resident rooms: Two (2) rooms will be shared and two (2) rooms will be private. 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 client. The mattresses and bedsprings were also checked for condition. 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: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

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: A & A ASSISTED LIVING HOMES	FACILITY NUMBER: 197610371
	VISIT DATE: 03/16/2023

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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 and measured within regulation at 116.1. The Licensee has appropriate non-skid mat in each shower. Towels and washcloths will not be shared.

Kitchen Area: LPA inspected kitchen equipment. The refrigerator was clean and in good operation. Dishes in good repair. Knives and cleaning supplies will be kept locked inaccessible in the kitchen.

Medications will be kept centrally stored and locked in a cabinet. Stove and refrigerator are clean and in good operation. LPA observed sufficient supply of 7 day non-perishable foods.

Outside: LPA toured the outside area. LPA observed a covered shaded area for clients. No bodies of water. The Licensee is renting the property. There is a ADA rental with a different access point that the Licensee does not have access to.

Garage/Laundry: There is no garage. The laundry is located in the locked office. Extra chemicals are also located in the locked office.

Files will be kept confidentially stored in the locked office 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. Exit interview completed. Copy of report delivered to Licensee/Applicant.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

LIC809 (FAS) - (06/04)

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