197610436-2-14-2024-31-AS-GSAO-D2FRXC-20240214122432

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610436
Report Date: 02/14/2024
Date Signed: 02/14/2024 12:25:05 PM

Document Has Been Signed on 02/14/2024 12:25 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	DAY & NIGHT ASSISTED LIVING		FACILITY NUMBER:	197610436
ADMINISTRATOR:	HAYRAPETYAN, VIKTORYA		FACILITY TYPE:	740
ADDRESS:	17655 NORDHOFF STREET		TELEPHONE:	(747) 344-3314
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY:	6	CENSUS: 0	DATE:	02/14/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Viktorya Hayrapetyan		TIME COMPLETED:	12:30 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	On 02/14/24, at 09:25am, Licensing Program Analyst (LPA), Gina Saucedo, conducted an announced visit to the facility for purpose of a pre-licensing evaluation. An application was submitted to Community Care Licensing Division-CCLD on 05/11/2023, Initial license for a Residential Care Facility for the Elderly, 60 years and older. The requested capacity is for one (1) bedridden, four (4) non-ambulatory and one (1) ambulatory, total of up to six (6) residents. Facility is a single-story home. Today's site visit consisted of LPA touring the physical plant at 10:05 AM inside and outside and observed the following: Bedrooms Staff: There is a bedroom designated for staff next to the kitchen on your left-hand side. Bedrooms Residents: There is a total of four (4) bedrooms for resident use. BEDROOMS APPROVED FOR ONLY AMBULATORY SHALL NOT BE USED FOR NON-AMB, PER 85087. There shall be no more than two clients per bedroom. Bedrooms #1 (one) and bedroom #2 (two) is for non-ambulatory occupancy and will be shared occupancy, bedroom number #3 (three) is for bedridden occupancy only and has a private bathroom which is cleared by the Fire Safety Inspection Request. Bedroom number #4 (four) will be a single, ambulatory bedroom. All the bedrooms have proper bedding, chairs, night stands, lamps in addition to overhead lighting. LIC 809C-continued

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024

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: DAY & NIGHT ASSISTED LIVING	FACILITY NUMBER: 197610436
	VISIT DATE: 02/14/2024

NARRATIVE

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The dining/living room Resident & Staff Files:
Has enough seating for staff and residents. The furniture is in good condition. The resident/staff files will be kept in an office area next to the living room/dining room area.

Linens & Hygiene Supplies:
Adequate supply of linen stored in the cabinets next to the bedrooms.

Emergency Phone Numbers, Exit Plan & Menu:

The facility has a working phone number land line. Fire Extinguisher located near kitchen door on your left-hand side mounted on the wall. It is fully charged and has a date of October 19, 2023.

Food Service:
Dishes, cups, and flat ware are stored in the kitchen cupboards, inspected and in good repair. Sharps are stored on your left side of the kitchen locked and secured. Food supply adequate stored in several cabinets and consists of the following cereal, canned goods, bottles of water. Dishwasher in kitchen properly installed and functioning. The refrigerator is in good condition and working.

Smoke Detectors:
There are smoke detectors/carbon monoxide through-out the house that were tested and work properly. They are hardwired and interconnected. There is also one in each room.

Water Temperature:
The water temperature was tested for the bathrooms are they are within regulation-114-119 Fahrenheit.

Medications, First-Aid Kit & Book
A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored in the kitchen area along with the medication will also be kept in this area secure, locked, and inaccessible to the residents.

LIC 809C-continued

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024

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: DAY & NIGHT ASSISTED LIVING	FACILITY NUMBER: 197610436
	VISIT DATE: 02/14/2024

NARRATIVE

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Pool/Jacuzzi:
There is no pool/jacuzzi in the facility.

Fire clearance:
Fire Clearance was approved on 10/23/2023 signed and dated.

Signal system:

The facility does have a signal system installed.

Administration:
The facility had submitted a Mitigation and Infection plan. The insurance plan is current, Family Councils, Personal Rights of Residents, Rights of Resident by Council, Non-Discrimination Policy, and YES sign is at the entrance of the facility against the wall on your right side. Component III was shown to the Administrator, orientation process was completed. The administrator licensee is Meri Mkrtumyan and was received on 05-22-2023.

Structure:
Overall Facility is a five (5) bedroom home with three (3) bathrooms, single-story with a car, detached garage in the back of the facility. The home has a fireplace which is covered with a metal screen cover and is inaccessible to the residents. There is one (1) washer and dryer located next to the kitchen area where there will be toxins which are in a locked area and inaccessible to the residents. This is where the staff bathroom will be located.

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.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024

LIC809 (FAS) - (06/04)

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