197610502-5-17-2024-31-AS-LNCA-D5CLTC-20240517090203

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610502
Report Date: 05/01/2024
Date Signed: 05/17/2024 09:02:10 AM

Document Has Been Signed on 05/17/2024 09:02 AM - 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:	SAFEWAY SENIOR LIVING		FACILITY NUMBER:	197610502
ADMINISTRATOR:	SARGSYAN, ANNA		FACILITY TYPE:	740
ADDRESS:	15725 LEMARSH STREET		TELEPHONE:	(818) 344-5555
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY:	6	CENSUS: 0	DATE:	05/01/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Anna Sarkisyan- Licensee Arsen Avagyan- Administrator		TIME COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted pre-licensing required visit and inspection of the facility. At 9:45 AM Anna Sarkisyan who is the licensee met with LPA, explained the reason for the visit. At 10:00 am, with the assistance of licensee, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are operational that are located each bedroom, the hallway and kitchen. There are carbon monoxide detectors that functions properly. The fire extinguisher is in the kitchen. The charge date is 12/9/2023. During the visit the facility is at 73 degrees Fahrenheit. The facility is fire cleared for three (3) non-ambulatory residents; two (2) ambulatory; (1) bedridden; bedroom #2 or bedroom #3 for non-ambulatory and bedridden; bedroom #1, bedroom #4 and bedroom #5 are cleared for ambulatory. Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap and stored properly as well. Knives were stored in a locked drawer in the kitchen. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Cleaning supplies, pesticides or toxic cleaning supplies were stored and locked away in the garage. Bedrooms: There were five (5) bedrooms designated for residents' use. Bedroom #1, bedroom #2, Bedroom #3, and bedroom #5 are private. Bedroom #4 is for shared use. All of the bedrooms are going to be used by residents, all of the bedrooms were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Continue to LIC 809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda	TELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: SAFEWAY SENIOR LIVING	FACILITY NUMBER: 197610502
	VISIT DATE: 05/01/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

BATHROOMS: LPA observed three (3) bathrooms that are clean and in good repair. All of the bathrooms are properly supplied with toilet papers, soap, and paper towels. The hot water temperature measured between 112.2°F. observed appropriate grab bar and had non-skid mat. Bathroom #1 is located inside bedroom #1. Bathroom #2 is located inside in the hallway in between bedroom #2 and bedroom #3. Hot water for bathroom #2 measured at 109.9°F. Bathroom #3 is located in the hallway. Hot water for bathroom #3 measured at 109.2°F.

COMMON AREAS: The facility maintains a comfortable temperature at 73°F. The living room and dining appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. Office is located by the dining area.

MEDICATION: The medications will be kept in the kitchen cabinet and the team observed the cabinet to be kept locked and inaccessible to residents in care.

SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility. At 10:20 AM they were tested and observed to be operational.

SURROUNDING GROUNDS: The backyard of the facility has sufficient yard space. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. The backyard is walled up. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients. There are no bodies of water. The driveway, passageway and entrance to the home was clear of obstructions. All entry and exit doors have a functional auditory alert when the doors open.

GARAGE: Garage is attached and accessible only through the lock door beside the kitchen. The washer and dryer appear to be in good condition. Laundry supplies are kept lock and inaccessible when not in use with supervision.

Component III was conducted with the administrator and licensee. Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) and 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 the Applicant/Administrator.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda	TELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2