197610386-4-28-2023-31-AS-MRUZ-CRBNFX-20230428102615

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610386
Report Date: 04/28/2023
Date Signed: 04/28/2023 10:27:14 AM

Document Has Been Signed on 04/28/2023 10:27 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	SUNLAND CARE HOME		FACILITY NUMBER:	197610386
ADMINISTRATOR:	AYVAZYAN, ZHIRAYR		FACILITY TYPE:	740
ADDRESS:	10942 QUILL AVE		TELEPHONE:	(818) 212-5050
CITY:	SUNLAND	STATE: CA	ZIP CODE:	91040
CAPACITY:	6	CENSUS: 5	DATE:	04/28/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Zhirayr Ayvazyan		TIME COMPLETED:	10:45 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

At 9:00 a.m., Licensing Program Analyst (LPA) Melissa Ruiz arrived at the facility to conduct an announced Pre-licensing inspection. Upon arrival LPA met with Applicant/Administrator Zhirayr Ayvazyan. This is a Change of Ownership Application for a Residential Care Facility for the Elderly. Facility is a single-story house with three (3) bedrooms and two (2) bathrooms. Facility has been approved for a capacity for six (6) residents, 5 of which can be non-ambulatory and 1 bedridden. A hospice waiver for 6 residents has been approved.

The physical plant was toured inside and out at 9:15 a.m. and LPA observed the following:

Residents: There are currently 5 residents receiving care and supervision. Residents appeared to be well groomed, happy, and enjoying breakfast and outdoor activities.

Common Area: LPA observed the living room and furniture to be clean and in good repair. The facility maintains a comfortable temperature at 70 degrees Fahrenheit. The air conditioner is operational. No firearms observed or will be maintained on the premises. The smoke alarm and carbon monoxide detector are dual functioning and hard wired throughout the facility. At 9:30 a.m. they were tested and deemed operational. The fire extinguisher was observed to be full and a purchase date of 3/22/23. Facility maintains a telephone landline and it was observed to be operational. Necessary precautions have been made to house dementia residents such as auditory alarms on all exit doors.

Kitchen Area: LPA observed the kitchen area to be in good repair and sanitary. There is a sufficient amount of perishable and non-perishable food. A drawer with a lock will be used to keep sharps locked and inaccessible to residents in care.

(Cont. on LIC809-C)

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

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: SUNLAND CARE HOME	FACILITY NUMBER: 197610386
	VISIT DATE: 04/28/2023

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
26
27
28
29
30
31
32

Kitchen appliances are clean and functional. The water temperature was taken and measures 117.4 degrees Fahrenheit. A locked file cabinet near the kitchen area contains resident medications, resident files, and staff files.

Bedrooms: Facility has three (3) bedrooms, all of which are shared. All bedrooms were toured and were observed with the appropriate furniture and bedding and sufficient lighting was observed. Extra linens and towels were observed in closets.

Bathrooms: Facility has two (2) bathrooms. Bathrooms were toured and were observed to be clean. Appropriate grab bars and non-skid mats were observed. Hand washing signs and paper towels were observed.

Garage: Facility has a detached garage in the backyard. Facility has washer and dryer located inside the garage. Laundry chemicals are stored in the garage and the garage will be used as a storage area and stores extra food supplies, toiletries, PPE supplies, and incontinence supplies.

Outside: LPA observed appropriate outdoor furniture with a shaded area for residents. There is a shed in the backyard that is used for storage and will remain locked and inaccessible to residents in care. There are no bodies of water.

Administrative: No deficiencies were observed. Applicant/Administrator has completed component III. LPA requested Administrator to submit their infection control plan, upon receiving their license.

This report will be sent to Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when the license has been approved. Report has been signed and delivered. Exit interview conducted with the Administrator.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2