197610508-7-10-2024-31-AS-LDLC-D72BX8-20240710012732

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610508
Report Date: 07/09/2024
Date Signed: 07/10/2024 01:28:47 AM

Document Has Been Signed on 07/10/2024 01:28 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:	SUNLAND CARE HOME		FACILITY NUMBER:	197610508
ADMINISTRATOR:	GEVORGYAN, RAZMASER		FACILITY TYPE:	740
ADDRESS:	10942 QUILL AVE		TELEPHONE:	(818) 331-8298
CITY:	SUNLAND	STATE: CA	ZIP CODE:	91040
CAPACITY:	6	CENSUS: 6	DATE:	07/09/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Razmaser Gevorgyan, Applicant/Administrator		TIME COMPLETED:	04:30 PM

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At 10:30AM, Licensing Program Analyst (LPA) Leizl de la Cerra arrived at the facility to conduct an unannounced Pre-licensing visit of Sunland Care Home. LPA met with Licensee/Administrator Zhirayr Ayvazyan and Applicant/Administrator,Razmaser Gevorgyan. This is a Change of Ownership Application for a Residential Care Facility for the Elderly. Facility is a single-story house with three (3) bedrooms and two (2) bathrooms. Fire Clearance was approved on 01/08/2024 for a capacity for six (6) residents, 5 of which can be non-ambulatory and 1 bedridden. A hospice waiver for 6 residents has been approved.

LPA conducted a physical plant tour inside and outside premises at 11:00AM. LPA observed the following:

COMMON AREA: LPA observed the living room and furniture to be clean and in good repair. The fireplace located in the living room is adequately closed and inaccessible. The facility maintains a comfortable temperature at 76 degrees Fahrenheit. The air conditioner is operational. The facility smoke alarm system is hard wired and interconnected. The facility uses a dual Carbon Monoxide/Smoke alarm detectors all over the common areas of the facility. At 11:40AM they were tested and deemed operational. Facility maintains a telephone land line and it was observed to be operational. Required postings were observed in the entry area.

KITCHEN AREA: LPA observed the kitchen area to be in good repair and sanitary. The kitchen is equipped with a refrigerator, dishwasher, microwave, oven and sink. Kitchen appliances are well maintained and functional. 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 drawer and inaccessible to residents in care. Water temperature was measured at 115.6 degrees Fahrenheit. A cabinet with a lock underneath the kitchen sink stores kitchen cleaning solutions and will remain locked and inaccessible to residents in care.

CONTINUED - LIC809-C.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Leizl De La Cerra	TELEPHONE: (818) 454-0632
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

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: SUNLAND CARE HOME	FACILITY NUMBER: 197610508
	VISIT DATE: 07/09/2024

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By the dining area. LPA observed a four drawer locked cabinet that contains all resident and staff records and medications. LPA observed the four drawer locked cabinet is inaccessible to residents in care. The fire extinguisher was observed to be fully charged and was last purchased on 02/13/24. The first-aid kit is complete.
Bedrooms: Facility has three (3) bedrooms, all of which are shared. All bedrooms were toured and were observed with the appropriate furniture, such as beds with clean beddings, night stands, closet space with dressers and sufficient lighting was observed at each bedroom. Extra linens and towels were observed in the hallway cabinet.

Bathrooms: Facility has two (2) bathrooms. Bathrooms were observed to be clean. Appropriate grab bars and non-skid mats were observed. Hygiene supplies are available to the residents. Water temperature was measured at 116.2 degrees Fahrenheit.

Garage Area: Facility has a detached garage in the backyard. Facility has a washer and dryer located inside the garage. Laundry chemicals are stored in the garage and the garage will be used as a storage area and stores extra food supplies, toiletries, PPE supplies, and incontinence supplies. The detached garage has a lock and will remain locked and inaccessible to residents in care

Surrounding Grounds: LPA observed appropriate outdoor furniture with a shaded area for residents. There is a locked shed in the backyard that is used for storage and will remain locked and inaccessible to residents in care. There are no bodies of water.

No deficiencies were observed.

Component III Orientation was conducted with the administrator/applicant during the visit.

LPA de la Cerra will notify the Centralized Applications Bureau (CAB) Analyst of the completed Change od Ownership Pre-Licensing inspection. The CAB Analyst will notify applicant when license is approved.
Exit interview was conducted and a copy of the signed report given to the applicant.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Leizl De La Cerra	TELEPHONE: (818) 454-0632
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

LIC809 (FAS) - (06/04)

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