197610507-5-10-2024-31-AS-MCAA-D55TGX-20240510144352

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610507
Report Date: 05/10/2024
Date Signed: 05/10/2024 02:44:02 PM

Document Has Been Signed on 05/10/2024 02:44 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	LOVEBIRD SENIOR LIVING I		FACILITY NUMBER:	197610507
ADMINISTRATOR:	SARGSIAN, ARMINE		FACILITY TYPE:	740
ADDRESS:	12840 JOLETTE AVE		TELEPHONE:	(818) 284-2502
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	6	CENSUS: 0	DATE:	05/10/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:38 PM
MET WITH:	Armine Sargsian, Anna Petrosyan		TIME COMPLETED:	02:45 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) Michael Cava conducted a Pre-Licensing Inspection with the applicant representative and administrator, Anna Petrosyan and Armine Sargsian. An Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on September 28, 2023. A fire clearance was approved on October 10, 2023 for five (5) non-ambulatory residents and one (1) bedridden resident, for a total capacity of six. The bedridden fire clearance is approved for bedroom #4. The applicant is also requesting a hospice waiver to retain six (6) residents. The smoke alarms and carbon monoxide detectors are dual and hard wired. The facility has two new fire extinguishers that was purchased on September 12, 2023. One is located in the kitchen and the other will be located in the backyard/patio area. A tour of the physical plant was initiated at approximately 12:45pm and the following was observed: KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven and sink. There was an adequate supply of nonperishable food and dining ware to accommodate a maximum capacity of six (6). Knives were observed locked in a kitchen drawer. Cabinet under the kitchen sink has a locking mechanism for toxins and cleaning supplies. BEDROOMS: There are four (4) bedrooms designated for client use. Bedroom #2 and #3 are private, while bedrooms #4 and #5 are shared. Per STD 850, bedroom #4 only, has the fire clearance for bedridden. The applicant furnished all the resident bedrooms with beds, night stand, chairs, dresser, bedding and linen. The bedrooms also have sufficient lighting and closet space. BATHROOMS: The facility has three (3) bathrooms. Two (2) bathrooms designated for residents, and one (1) is designated for staff. The bathrooms, designated for resident use were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured at 118 degrees.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LOVEBIRD SENIOR LIVING I	FACILITY NUMBER: 197610507
	VISIT DATE: 05/10/2024

NARRATIVE

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COMMON AREAS: These included the living room which is equipped with two couches, recliner, television, and a table. There is a fireplace with a screen but will be non-operational. No fireplace tools or fixtures present. The dining area has a large dining room table to accommodate between six (6) to eight (8). There were no visible immediate hazards.

GARAGE: The garage will be used as storage for supplies. It will be kept off limits and inaccessible to the residents in care.

Laundry: Laundry area is located by the kitchen. Cleaning supplies and detergents are kept in a cabinet, above the washer dryer. Cabinet has a locking mechanism.

MEDICATIONS: The medication cabinet is located in the kitchen. Cabinet will be kept locked to make medications inaccessible to the residents. There is a complete first aid kit and manual stored inside the medication cabinet.

OFFICE/STAFF WORKSTATION: Administrator office (room #1), is located near the front entrance. Resident and personnel files will be maintained in a locked filing cabinet there.

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 patio and backyard furniture to accommodate the six (6) residents. The facility backyard has sufficient yard space. There is no swimming pool or bodies of water.

Both Anna Petrosyan and Armine Sargsian received the Component III power point presentation during their pre-licensing at LOVEBIRD SENIOR LIVING INC #197610475 on December 13, 2023. It will be waived at this time.

Pursuant to Title 22, Division 6 of the CA Code of Regulations, the facility's physical environment appears to be compliant and ready for licensure. CAB will be advised and a copy of this report provided.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

LIC809 (FAS) - (06/04)

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