197610483-12-6-2023-31-AS-NRED-CY9SRX-20231206130705

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610483
Report Date: 12/06/2023
Date Signed: 12/06/2023 01:07:10 PM

Document Has Been Signed on 12/06/2023 01:07 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	LIFELONG SENIOR LIVING		FACILITY NUMBER:	197610483
ADMINISTRATOR:	KAPIKYAN, ANDRANIK		FACILITY TYPE:	740
ADDRESS:	16003 LUDLOW ST		TELEPHONE:	(818) 371-5979
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	6	CENSUS: 0	DATE:	12/06/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Liana Gafikyan		TIME COMPLETED:	01:10 PM

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At 10:40 a.m. on 12/06/2023, Licensing Program Analysts (LPAs) Nicholas Reed and Michael Cava conducted an announced prelicensing inspection. LPAs met with the applicant and administrator and disclosed the reason for the visit. LPAs, applicant, and administrator toured the facility inside and out at 10:50 a.m.. No immediate health and safety hazards were observed during this visit.

It is a single story building with four (04) bedrooms, two (02) bathrooms, kitchen. garage, common areas, and outdoor areas. It has an approved fire clearance for non-ambulatory residents in Bedroom #1 and Bedroom #3, a bedridden resident in Bedroom #2, and an ambulatory resident in Bedroom #4. Hospice waivers for 6 residents. The facility uses surveillance cameras in common areas and exterior areas.

At the main entrance, LPAs observed postings for personal rights, non-discrimination notice, administrator certificate, Ombudsman contact, complaint contact poster, and rights of resident councils. LPAs advised that the complaint poster must be 20” x 26”, and the facility should also post a blank copy of the admission agreement, visitation policy, emergency disaster plan, and a weekly menu. LPAs also observed facility sketches with evacuation procedures clearly labelled throughout the facility.

All emergency exit paths were free from obstructions. The rear exit gate was unlocked with a self-closing latch. The rear exit gate shall remained unlocked as per the facility’s fire clearance. Front gates were locked and approved by the city Fire Inspector. At 10:55 a.m., the carbon monoxide detector at the front was tested and operational. At 11:00 a.m. today, the smoke detector in Bedroom #1 was tested and operational. During the test, three (03) out of three (03) fire doors closed. At approximately 11:05 a.m. LPA observed fully charged fire extinguishers at the front and in the kitchen. They were last inspected on 11/16/2022. The applicant set a reinspection date for 12/07/2023. At 11:10 a.m. today, six (06) out of six (06) auditory alarms were heard on and functioning. At 11:15 a.m. LPAs tested the house phone to be operational.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LIFELONG SENIOR LIVING	FACILITY NUMBER: 197610483
	VISIT DATE: 12/06/2023

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The facility has 4 bedrooms. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. The ramp and handrails leading from Bedroom #2 were in good condition

The facility has 2 bathrooms. 1 bathroom is private to Bedroom #4, and 1 is shared. All bathrooms contained liquid soap, trash can with lids, grab bars near the toilet and shower, and a non-skid mat in the shower. The shared bathroom used a revolving hand drying device. The shared bathroom used paper towels. At approximately 11:20 a.m. LPAs measured the water temperature to be 108.8 degrees Fahrenheit.

Walls, floors, windows, screens, and blinds were clean and in good repair. At 11:25 a.m. LPA measured the room temperature to be 72 degrees Fahrenheit. Board games, books, and activities were observed in the living room. Additional linens and beddings were stored in an outdoor storage area.

LPAs observed an adequate supply of non-perishable foods in the kitchen. The stove hood was clean. Appliances were in good condition. Sharps were locked below the counter. Cleaning solutions were locked below the sink. LPAs observed a storage area behind the kitchen for files, medications, and supplies.

A washing machine and dryer were located in the rear of the facility. Both were in working order. Detergents were locked in a storage cabinet.

LPA observed a patio area in the rear of the facility which was shaded by an awning. The patio contained furniture in good condition.

LPAs, applicant, and administrator reviewed Component III at 12:00 p.m. today.

During today's inspection, the facility needs additional postings mentioned above, a reinspection for fire extinguishers, and a complete first aid kit. Pre-Licensing is incomplete with deficiencies to be resolved by 12/08/2023. Applicant to notify LPAs of corrections and send photographs of corrections prior to licensure.

Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

LIC809 (FAS) - (06/04)

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