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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610394
Report Date: 04/28/2023
Date Signed: 06/01/2023 03:06:22 PM

Document Has Been Signed on 06/01/2023 03:06 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:CANTARA LUXURY LIVINGFACILITY NUMBER:
197610394
ADMINISTRATOR:ASIRYAN, AREVHATFACILITY TYPE:
735
ADDRESS:10509 CANTARA STREETTELEPHONE:
(323) 879-5408
CITY:SUN VALLEYSTATE: CAZIP CODE:
91352
CAPACITY: 4CENSUS: 0DATE:
04/28/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Arevhat Asiryan TIME COMPLETED:
12:45 PM
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At 11:10 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 Arevhat Asiryan. This is a new application for an Adult Residential Facility. Facility is a single-story house with four (4) bedrooms and two (2) bathrooms. Facility has been approved for a capacity for four (4) clients, all of which must be ambulatory. Applicant is waiting to be vendored by Regional Center.

The physical plant was toured inside and out at 11:15 a.m. and LPA observed the following:

Common Area: LPA observed the living room and furniture to be clean and in good repair. LPA observed the dining area to be clean. 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. Facility maintains a telephone landline and it was observed to be operational. Facility maintains a temperature of 68 degrees Fahrenheit. The laundry area is in the hallway and medications and files will be stored in a locked cabinet along the hallway. A first aid kit was also observed.

Kitchen Area: LPA observed the kitchen area to be in good repair and sanitary. There is a sufficient amount of start of perishable and non-perishable foods. A drawer with a lock will be used to keep sharps locked and inaccessible to clients in care. Kitchen appliances are clean and functional. The water temperature was taken and measures 118 degrees Fahrenheit.

(cont. on LIC809-C)

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
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)
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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: CANTARA LUXURY LIVING
FACILITY NUMBER: 197610394
VISIT DATE: 04/28/2023
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Bedrooms: Facility has four (4) bedrooms, 3 of which are for client use and 1 for staff. 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 bedrooms.

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

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

Administrative: Applicant/Administrator has completed Component III. Infection control plan is on file.

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.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
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)
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