197610471-11-20-2023-31-AS-LNCA-CXRR5G-20231120114306

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610471
Report Date: 11/20/2023
Date Signed: 11/20/2023 11:43:15 AM

Document Has Been Signed on 11/20/2023 11:43 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:	BOARD AND CARE AYC		FACILITY NUMBER:	197610471
ADMINISTRATOR:	BABAYAN, KNARIK		FACILITY TYPE:	740
ADDRESS:	14950 POLK STREET		TELEPHONE:	(562) 600-0606
CITY:	SYLMAR	STATE: CA	ZIP CODE:	91342
CAPACITY:	6	CENSUS: 0	DATE:	11/20/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Knarik Babayan- Licensee & Anahit Ohanyan- Administrator		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	On 11.20.2023 Licensing Program Analyst (LPA) Leslie Ngo-Castaneda arrived at facility at 9:45am conducted a pre-licensing inspection with the applicant representative and administrator. Knarik Babayan (licensee) and Anahit Ohanyan (administrator) was greeted upon entering the facility. An application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on July 25, 2023. A fire clearance was approved on September 13, 2023 for five (5) non-ambulatory residents and one (1) bedridden resident, for a total capacity of six (6). The applicant is also requesting a hospice waiver to retain five (5) residents. The smoke alarms and carbon monoxide detector are hard wired and inter-connected. The facility has one new fire extinguishers that was purchased on August 20, 2023. One fire extinguisher is located in between the dining room and the kitchen area. A tour of the physical plant was initiated at approximately 9:50am and the following was observed: KITCHEN: The facility has a kitchen area that is equipped with a refrigerator, microwave oven and sink. The hot water delivered is measured at 118.9 degrees F. There were adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). LPA inspected the kitchen and observed gas stove and refrigerator to be clean and working. Knives and sharps are stored in a locked kitchen drawer. Cleaning agents are also stored under the sink with a locking mechanism. BEDROOMS: There are four (4) bedrooms designated for client use in the hallway. Bedroom #1 and #2 are cleared to be private rooms. Bedrooms #3 and #4 will be used as a shared bedroom, where bedroom #4 will have the bedridden resident, a fire clearance (per STD 850) was cleared and given. The applicant furnished the resident bedrooms with beds, night stand, chairs, dresser, bedding, and linen. The bedrooms have sufficient lighting and closet space. The linens were stored in the storage space in each residents bedrooms. Continue to LIC 809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda	TELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

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: BOARD AND CARE AYC	FACILITY NUMBER: 197610471
	VISIT DATE: 11/20/2023

NARRATIVE

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BATHROOMS: The facility has two (2) bathrooms. Staff has their own bathroom with shower and tub for staff. The other bathroom is located by the end of the hallway, in between bedrooms #3 and #4. The bathroom were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured at 116.1 degrees Fahrenheit.

COMMON AREAS: The common areas were appropriately furnished these included the living and dining room area. The living room was equipped with couch, non-audible camera, a television, tables and chairs. The LPA observed entertainment equipment and games for activities. The dining table is large enough to seat six (6) individuals. There is no fireplace in the facility. The facility has maintained a temperature of 70 degrees Fahrenheit. There were no visible immediate hazards. The facility has adequate linen, water, and emergency kits.

LAUNDRY ROOM: The laundry room is located in the kitchen. It was observed with a locked door to make it inaccessible to the residents. The washer and dryer are brand new. All chemicals were stored and locked in the laundry room.

MEDICATIONS: The medications will be located in the kitchen. It has a locking mechanism.

OFFICE/STAFF WORKSTATION: The facility has a staff workstation that is in between the kitchen and the living room where designated storage cabinet for residents and staff records are located in a lock cabinet. The first-aid kit is complete.

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. There is sufficient outdoor space with seating and a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises. Pursuant to Title 22, Division 6 of the CA Code of Regulations, the facility's physical environment appears to be compliant and ready for licensee. CAB will be advised, and a copy of this report provided. No health and safety hazard were noted during this visit. Licensee shall contact LPA once the first resident is admitted. Exit interview was conducted and a copy of report was issued.

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

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda	TELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

LIC809 (FAS) - (06/04)

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