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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610498
Report Date: 01/24/2024
Date Signed: 01/24/2024 12:01:22 PM


Document Has Been Signed on 01/24/2024 12:01 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:LOS ANGELES ASSISTED LIVINGFACILITY NUMBER:
197610498
ADMINISTRATOR:ARZUMANYAN, ANUSHFACILITY TYPE:
740
ADDRESS:15216 CHATSWORTH STREETTELEPHONE:
(424) 666-5666
CITY:MISSION HILLSSTATE: CAZIP CODE:
91345
CAPACITY:6CENSUS: 0DATE:
01/24/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Harut Arzumanyan - RepresentativeTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Gary Tan conducted a Pre-Licensing Inspection with the applicant representative Harut Arzumanyan. The applicant is "Los Angeles Assisted Living". A fire clearance was approved on 12/27/23 for six (6) non-ambulatory residents, two (2) of which may be bedridden on Room #5. The applicant has an approved hospice waiver for six (6) residents.

The facility has a total of eight (8) bedrooms and three (3) bathrooms. One of the room is designated as an office and the other one is designated for staff use only. One (1) bathroom is also designated for staff use.

A tour of the physical plant was initiated at approximately 10:00 AM and the following was observed:

KITCHEN: The facility has a Kitchen that is equipped with a refrigerator, microwave, stove, dishwasher and sink. There was an adequate supply of perishable and nonperishable food. Knives were observed locked in a kitchen drawer. Cleaning supplies and other toxins will be stored in the cabinet in the bedroom hallway which was locked during visit.

BEDROOMS: There are six (6) bedrooms designated for client's use, all private. The applicant furnished the resident bedrooms with beds, night stand, chairs, dressers, bedding and linen. The bedrooms have sufficient lighting and storage.

BATHROOMS: The facility has two (2) shared bathrooms for clients' use. The bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water temperature was measured at a range of 115.7°F to 116.2°F.

LAUNDRY ROOM: The laundry room is located in the staff bathroom. Laundry detergents and other cleaning agents were locked in a cabinet along the bedroom hallway by the door. The bathroom/laundry room was observed to be locked during visit. (continued on LIC 809-C)

SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024
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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: LOS ANGELES ASSISTED LIVING
FACILITY NUMBER: 197610498
VISIT DATE: 01/24/2024
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(continued from LIC 809)

COMMON AREAS: These included the living room and the dining area. Living room was furnished with chairs and side tables. The living room area was furnished with a television, a coffee table and sofas to sit the capacity of the facility. There were no visible immediate hazards. Cleaning supplies and chemicals are stored and locked in a cabinet in the bedroom hallway. There is a working telephone line and internet accessible to residents. Dual smoke/carbon monoxide alarms were tested and observed to be operable. Fire extinguishers were last bought on 01/09/24. One (1) is located in the living room area and the other in the bedroom hallway. The facility is equipped with sprinkler system and closed circuit television system in the common areas.

MEDICATIONS: The medication cabinet is located in the kitchen and has has a locking mechanism. A complete first aid kit is located inside the medication cabinet.

Staff/Resident Records: Staff and resident records will be kept in the filing cabinet inside the office.

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 covered patio and backyard furniture to accommodate the residents. The Garage is detached to the house, locked and inaccessible to residents and currently being used as tool shed and old equipment storage. There is another storage at the back end of the lot but observed to be locked and inaccessible to residents. There is no body of water in the facility.

Component III was waived with the approval of LPM Troy Agard. Licensee representative has been an administrator with his other facility for about four (4) years. No deficiencies were observed.

This report will be sent to Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when the license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
LIC809 (FAS) - (06/04)
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