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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610475
Report Date: 12/13/2023
Date Signed: 12/13/2023 02:16:19 PM


Document Has Been Signed on 12/13/2023 02:16 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:LOVEBIRD SENIOR LIVING INCFACILITY NUMBER:
197610475
ADMINISTRATOR:SARGSIAN, ARMINEFACILITY TYPE:
740
ADDRESS:13153 CONSTABLE AVENUETELEPHONE:
(818) 284-2502
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:6CENSUS: 0DATE:
12/13/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Armine Sargsian, Anna PetrosyanTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Michael Cava conducted a Pre-Licensing Inspection with the applicant representative and administrator, Anna Petrosyan and Armine Sargsian. An Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on August 9, 2023. A fire clearance was approved on September 19, 2023 for five (5) non-ambulatory residents and one (1) bedridden resident, for a total capacity of six. The applicant is also requesting a hospice waiver to retain six (6) residents. The smoke alarms and carbon monoxide detectors are dual and hard wired. The facility has one new fire extinguishers that was purchased on September 12, 2023. It is located in the kitchen

A tour of the physical plant was initiated at approximately 1:00pm and the following was observed:

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven and sink. There was an adequate supply of 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 #3 are private, while bedrooms #2 and #4 are shared. Per STD 850, bedroom #4 only, has the fire clearance for bedridden. The applicant furnished all the resident bedrooms with beds, night stand, chairs, dresser, bedding and linen. The bedrooms also have sufficient lighting and closet space.

BATHROOMS: The facility has two (2) bathrooms. Bedroom #4 has it's own bathroom with a bathtub, but it won't be utilized for residents. Both bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured at 105 degrees.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023
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: LOVEBIRD SENIOR LIVING INC
FACILITY NUMBER: 197610475
VISIT DATE: 12/13/2023
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COMMON AREAS: These included the living room which were equipped with a couch, chair, television, and table. There is a fireplace with a screen but will be non-operational. The key will be stored and inaccessible to residents. No fireplace tools or fixtures present. The dining area has a large dining room table to accommodate between six (6) to eight (8). There were no visible immediate hazards.

GARAGE/LAUNDRY ROOM: The laundry room is located in the garage. Door to the garage has an alert to notify staff that the entry door to the garage is open. No cleaning supplies observed, or will be kept in the garage. The washer/dryer are brand new. Garage will also be used as extra storage space for equipment, PPE supplies, and emergency water.

MEDICATIONS: The medication cabinet is located in the dining room. Cabinet has a locking mechanism to insure medications will be inaccessible to residents.

OFFICE/STAFF WORKSTATION: Staff workstation is located by the exit to the backyard.. Resident and personnel files will be maintained in a locked filing cabinet there.

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 no swimming pool or bodies of water.

In addition to the Pre-Licensing inspection, a Component III power point presentation was also held between/approximately 12:20pm and 1:00pm

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 MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
LIC809 (FAS) - (06/04)
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