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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610491
Report Date: 05/03/2024
Date Signed: 05/03/2024 12:33:11 PM

Document Has Been Signed on 05/03/2024 12:33 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:A PEPPER HOUSEFACILITY NUMBER:
197610491
ADMINISTRATOR/
DIRECTOR:		CHALABYAN, LEVONFACILITY TYPE:
735
ADDRESS:2124 N. PEPPER STREETTELEPHONE:
(818) 472-7878
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY: 6CENSUS: 0DATE:
05/03/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Licensee, Levon ChalabyanTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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At 9:00AM Licensing Program Analyst (LPA), Antonia Alvizar-Ettima conducted an announced Pre-Licensing visit to the above facility and met with Licensee.

Fire Clearance was approved on 01/11/2024 for a maximum capacity of six (6) Non-Ambulatory 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 located in a residential community. 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, dish washer, microwave oven and sink. At approximately 9:20AM, LPA observed adequate supplies of perishable and 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. Full charged Fire Extinguisher with receipt dated 07/07/23.

LAUNDRY ROOM: The laundry room is located next to dinning area with a locked door. The washer/dryer appear to be in good condition. Laundry supplies are kept inaccessible when not in use with supervision.

BEDROOMS: There are five (5) bedrooms designated for client use. All bedrooms are furnished with beds, dressers and required bedding and linen. The bedrooms have sufficient closet space and have sufficient lighting.

BATHROOMS: LPA observed all bathrooms clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bar and had non-skid mat. Water temperature was between 116.1 -118.2 °F which is within regulation.


Continue on LIC809-C

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2024
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: A PEPPER HOUSE
FACILITY NUMBER: 197610491
VISIT DATE: 05/03/2024
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COMMON AREAS: The facility maintains a comfortable temperature at 72°F. The living room and dining area appeared clean and were properly furnished. There were puzzles, books, balls, and board games. No obstructions and or tripping hazards throughout the facility.

MEDICATION ROOM: The medication and facility staff/resident files will be kept in a locked office next to room #2.

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

SURROUNDING GROUNDS: The entrance to the home is gated. The back of the facility has sufficient yard space. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. The backyard is fenced. The attached garage is kept locked and currently being used only by Licensee for storage. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients. There are no bodies of water or weapons in the facility.


Upon completing inspection of the physical plant, LPA noted that the front side fance did not completely separate this Adult Residential facility from the Children Day-Care next-door. Based on LPA observation, these yards need to be completely separated. This issue was discussed with Licensee The licensee indicated he will completely separate the yards with a fence. LPA informed the Licensee that the physical plant is not meeting Pre-Licensing requirements. Licensee will needs to submit a picture of a fence separating the front side yards in order to meet Pre-Licensing requirements.

Component III: Upon review of the Licensing records, LPA noted that on 02/18/2010 the applicant representative/Licensee Levon Chalabyan completed the Component III during Pre-Licensing visit at facility “A Burbank Residential Care #197607871” at which time the applicant was explained how to operate the facility within substantial compliance and had an opportunity to ask questions. LPA Alvizar-Ettima spoke with LPM Margaryan over the phone and Component III was waived based on LPA's discussion with the LPM.


Based on inspection and observation, the physical plant is not in compliance with Title 22 Regulations at this time.Upon receiving photos of requested side fence. this report will be forwarded to the Centralized Application Bureau (CAB) for completion. The applicant/Licensee will be notified by the CAB Analyst when your license has been approved.



Exit interview was conducted and with a copy of this report was provided to Levon Chalabyan.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
LIC809 (FAS) - (06/04)
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