197610477-12-12-2023-31-AS-HRAI-CYFRSR-20231212121709

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610477
Report Date: 12/12/2023
Date Signed: 12/12/2023 12:17:24 PM

Document Has Been Signed on 12/12/2023 12:17 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:	GREEN LIFE CARE FACILITY INC		FACILITY NUMBER:	197610477
ADMINISTRATOR:	BEIKJANI, KATRIN		FACILITY TYPE:	740
ADDRESS:	18627 ARMINTA STREET		TELEPHONE:	(818) 279-4506
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY:	6	CENSUS: 0	DATE:	12/12/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Katrin Beikjian, Administrator		TIME COMPLETED:	12:30 PM

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At 9:00 am, Licensing Program Analysts (LPA), Huma Rahimi conducted an announced Pre-Licensing visit to the above facility and met with Administrator Katrin Beikjian and the owner Mineli Manukian. LPA conducted an entrance interview with the Administrator. At the time of this visit LPA did not observed any residents present in the facility. Fire Clearance dated 10/17/2023 and received for five (5) Non-ambulatory and one (1) Bedridden (room #3) residents. The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. The facility is a single-story building. Today's site visit consisted of LPA touring the physical plant inside and outside and observed the following:

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven, sink. Stove was observed in a good working condition. LPA observed adequate supplies of nonperishable food and dining ware to accommodate a maximum capacity of six (6). All knives and sharps are observed to be locked in a kitchen cabinet and inaccessible to residents. Administrator/Licensee was informed that the locking mechanism shall be maintained and inaccessible at all times. Fire Extinguisher was last purchased on 09/12/23, and was full. The medication will be kept in a locked cabinet in the kitchen.

BEDROOMS: There are four (4) bedrooms designated for residents use. Bedroom (3) is Bedridden and three (3) are Non-ambulatory. LPA observed a model which was furnished with beds, dressers and required bedding and linen. The bedrooms have sufficient closet space and have sufficient lighting. and chest drawers. Facility will have a live-in staff at the facility in the bedroom (1). Bedroom # 4 and bedroom # 5 are shared. All bedrooms have a functional alarm system. .

Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

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: GREEN LIFE CARE FACILITY INC	FACILITY NUMBER: 197610477
	VISIT DATE: 12/12/2023

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BATHROOMS: At 9:47am LPA observed bathroom # 1 is clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed bathroom to have appropriate grab bar and a non-skid mat . The water temperature was noted at 119°.3. The facility is using bathroom # 2 for staff and visitors only.

COMMON AREAS: LPA observed all common areas to be clean in good repair. The facility maintains a comfortable temperature at 72°F. The living room and dinning rooms were properly furnished. No obstructions and or tripping hazards throughout the facility.

Office Area: LPA observed an office area between dinning room and kitchen. The residents and staff file will be kept in a locked chest drawers.

LAUNDRY ROOM: The laundry room is located behind the kitchen which has an entry to garage. LPA observed a door with a lock. The washer/dryer appear to be in good condition. Laundry supplies are kept inaccessible when not in use with supervision.

SURROUNDING GROUNDS: The back of the facility has sufficient yard space. LPA observed appropriate outdoor furniture, LPA observe a covered shaded area for residents. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents. There is no swimming pool or bodies of water in the facility. The facility has a back-house which will have no residents and the owner of the house will live in it. The back-house will be kept locked all the times when the owner is away.

SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility. They were tested and observed to be operational.

Activity Room: LPA observed an activity room for residents use with an adequate amount of activities. The activity room is located in the front of the house adjacent to living and dinning rooms.

Component III was conducted with the Administrator.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

LIC809 (FAS) - (06/04)

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