197610431-9-29-2023-31-AS-GSAO-CW5Q82-20230929115601

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610431
Report Date: 09/29/2023
Date Signed: 09/29/2023 11:56:47 AM

Document Has Been Signed on 09/29/2023 11:56 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	SUNRISE AT LINDLEY II		FACILITY NUMBER:	197610431
ADMINISTRATOR:	MELIKSETYAN, LUSINE		FACILITY TYPE:	740
ADDRESS:	9953 LINDLEY AVE		TELEPHONE:	(747) 218-9141
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY: 6		CENSUS: 0	DATE:	09/29/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Lusine Meliksetyan		TIME COMPLETED:	12:00 PM

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	Licensing Program Analysts (LPAs) Gary Tan and Gina Saucedo conducted an announced Pre-Licensing visit to this facility and met with Licensee representative Lusine Meliksetyan. The applicant is "Sunrise AT Lindley II". Fire Clearance dated 06/01/23 was received for six (6) residents-five (5) non-ambulatory and one (1) bedridden in bedroom #6. 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. Facility is a single story home. Today's site visit consisted of LPA's touring the physical plant at around 10:00 AM inside and outside and observed the following: The facility smoke alarm system is hard wired and interconnected and have a sprinkling system. The fire extinguishers are located near the main entrance door and dining area and were observed to be fully charged and last bought on 09/11/2023. The facility uses a dual Carbon Monoxide/Smoke alarm detectors all over the common areas of the facility. Alarms were tested and observed to be operational. Hot water was tested in the common bathrooms and measured between 114.4F and 116.6 F. There is a functioning telephone on the premises which was tested. An emergency exit plan/sketch is posted on the hallway wall with other posting requirements. There are six (6) resident bedrooms, room #1 and room #6 have their, own private bathrooms. There is a total of six (6) bathrooms. All resident bedrooms were observed to be appropriately furnished. The common areas (living room, kitchen, and dining areas) were appropriately furnished and lighting was adequate. The living room has a comfortable furniture and dining room table. Residents, staff records and medications will be stored in a designated secured cabinet in the dining area. The first aid kit is readily available. The bathrooms have appropriate grab bars installed and non-skid mats. (continued to LIC 809-C)

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNRISE AT LINDLEY II	FACILITY NUMBER: 197610431
	VISIT DATE: 09/29/2023

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(continued from LIC 809)

The kitchen knives and sharps are stored in a locked drawer in the kitchen using a magnetic lock. Kitchen cleaning supplies are stored in a locked cabinet below in the kitchen. Laundry detergents, cleaning supplies and other toxins are stored in a locked cabinet below the kitchen sink. The laundry area is located in the hallway near the kitchen. The necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on all doors. Auditory alarms were tested and observed to be operational. Facility appears to be clean and in good repair. Appliances in the kitchen appeared to be functional.

There is a screening station immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. Required covid 19 posters are posted all over the facility. The facility had submitted a Mitigation and Infection plan.

There is a sitting area in the back yard for residents to conduct outdoor activities. The backyard is fenced. There is no body of water in the facility.

Component III was waived as approved by LPM Troy Agard as the licensee has one (1) other existing facility.

Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.

Exit interview conducted and copy of this report issued

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC809 (FAS) - (06/04)

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