197610444-5-7-2024-31-AS-MCAA-D52T4B-20240507142341

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610444
Report Date: 05/07/2024
Date Signed: 05/07/2024 02:24:15 PM

Document Has Been Signed on 05/07/2024 02:24 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:	SUN VALLEY RESIDENTIAL CARE		FACILITY NUMBER:	197610444
ADMINISTRATOR:	ATOYAN, PETER		FACILITY TYPE:	740
ADDRESS:	8667 HERRICK AVE		TELEPHONE:	(818) 404-0290
CITY:	SUN VALLEY	STATE: CA	ZIP CODE:	91352
CAPACITY:	6	CENSUS: 6	DATE:	05/07/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Rebecca Durgaryan, Peter Atoyan		TIME COMPLETED:	02:30 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	Licensing Program Analyst (LPA) Michael Cava conducted a Pre-Licensing Inspection with the applicant representative and administrator, Peter Atoyan and Rebecca Durgaryan. A Change in Ownership (CHOW) Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on May 30, 2023. A fire clearance was approved on January 29, 2024 for five (5) non-ambulatory residents and one (1) bedridden resident, for a total capacity of six. The bedridden fire clearance is for room #4. The garage is to be used as a garage only. The applicant is also requesting a hospice waiver to retain six (6) residents. The smoke alarms and carbon monoxide detector are hard wired and inter-connected. The facility has two new fire extinguishers that was purchased on October 15, 2023. One fire extinguisher is located in dining room area, and the other at the kitchen. A tour of the physical plant was initiated at approximately 9:45am and the following was observed: KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven and sink. There were adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). Knives were observed locked in a kitchen drawer. BEDROOMS: There are four (4) bedrooms designated for client use. Bedroom #1 and #4 are private rooms, with bedroom #4 having a bedridden fire clearance (per STD 850). Bedrooms #2 and #3 are shared rooms. The applicant furnished the resident bedrooms with beds, night stand, chairs, dresser, bedding and linen. The bedrooms have sufficient lighting and closet space. BATHROOMS: The facility has two (2) bathrooms for the resident's use. Both bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured at 109.4 degrees.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUN VALLEY RESIDENTIAL CARE	FACILITY NUMBER: 197610444
	VISIT DATE: 05/07/2024

NARRATIVE

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COMMON AREAS: These included the living room and dining room. The living room was equipped with furniture, a television, tables and chairs. There is a fireplace with a screen. It is non-operational. No fireplace tools or fixtures present. The dining area has a large dining room table to accommodate six (6). There were no visible immediate hazards.

GARAGE/LAUNDRY ROOM: The washer and dryer is located in the garage, which is kept locked. The garage is also used as extra storage for non-perishable and emergency food supplies and water. There is another refrigerator in the garage for additional perishable food items.

MEDICATIONS: The medications are kept locked in a kitchen cabinet.

Resident Files: LPA conducted a file review of random resident records to insure compliance of licensing forms. Resident files are kept locked in cabinet, at the kitchen.

Staff Files: Staff files are also kept in a locked cabinet at the kitchen.

OFFICE/STAFF WORKSTATION: There is a staff workstation located at the corner of the living room.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. All entry and exit doors have a functional auditory alert when the doors open. The backyard of the facility has a patio and backyard furniture to accommodate the six (6) residents. The facility backyard has sufficient yard space. There is a swimming pool that is fenced all around with a gate that will be kept locked at all times. The fence surrounding the swimming pool is approximately 5 feet high all around its parameters. You will need a key to unlock the padlock to gain entry to the swimming pool as it is kept locked at all times.

In addition to the Pre-Licensing inspection, a Component III power point presentation was also held.

Pursuant to Title 22, Division 6 of the CA Code of Regulations, the facility's physical environment appears to be compliant and ready for licensure. CAB will be advised and a copy of this report provided.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024

LIC809 (FAS) - (06/04)

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