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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610374
Report Date: 05/17/2023
Date Signed: 05/17/2023 12:29:25 PM

Document Has Been Signed on 05/17/2023 12:29 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:WELL SENIOR CAREFACILITY NUMBER:
197610374
ADMINISTRATOR:ERITSIAN, ARMINE AMYFACILITY TYPE:
740
ADDRESS:4969 CHIMINEAS AVETELEPHONE:
(818) 599-3366
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY: 5CENSUS: 0DATE:
05/17/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Armine EritsianTIME COMPLETED:
12:35 PM
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At 9:35 am Licensing Program Analyst (LPA) Tihesha Smith conducted an announced pre-licensing
visit with administrator. Identification of the Applicant/administrator was verified by CA driver’s
license.

The facility has a capacity of five (5). Application received four (4) non-ambulatory and 1-bedridden client.
Purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with the
rules and regulations of California Code of Regulations, Title 22, Division 6. The facility is a
single-story building.

Today's site visit consisted of LPA touring the physical plant inside and outside and observed the
following: The common areas (kitchen, living room, and dining areas) were appropriately furnished, and
lighting was adequate. The living room has a television and comfortable furniture.
The facility has a variety of adequate perishable and non-perishable food supply. Appliances in the
kitchen appeared to be functional. The sharps are stored and locked in drawer in kitchen.

Laundry room located in garage. Washer and dryer observed to be in good repair. Toxins stored in locked garage.
There is one (1) fire extinguisher: located in kitchen area attached to wall near patio door. Fire extinguisher
observed to be fully charged. Dual Smoke and Carbon Monoxide detectors were observed all over
the facility, tested, and observed to be operational at approximately 11:20 am.

There is a functioning telephone/landline on the premises. An emergency exit plan/sketch is posted


On living room wall next to kitchen.
There are three (3) bathrooms in the facility: The hot water was tested for the bathrooms and
measured at 118.6,118.6 and 117.1 °F. The bathrooms have non-skid mats, trash cans with lids
and functional grab bars
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: WELL SENIOR CARE
FACILITY NUMBER: 197610374
VISIT DATE: 05/17/2023
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(Cont. from 809)

There are three (3) client bedrooms: no room is designated for staff use. Client bedrooms were
observed to be appropriately furnished with a bed, nightstand, dresser, and chair. Extra linen stored in clients’ room.
Medications are stored in locked upper kitchen cabinet next to refrigerator. Client and staff records
stored in locked metal file in kitchen.

There are two (2) patio areas: one covered area with patio table and chairs for clients use and a non-covered area with sufficient seating for clients in the backyard. There is no body of water
at the facility.

Component III was conducted with the administrator and administrator confirmed understanding of
Title 22.

Facility appears to be clean and in good repair. At time of visit this facility is ready to be licensed.

This report will be forwarded to the Centralized Application Bureau (CAB).

Exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2