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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610509
Report Date: 02/07/2024
Date Signed: 02/07/2024 01:17:36 PM


Document Has Been Signed on 02/07/2024 01:17 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:KK SUNNYBRAE SENIOR LIVINGFACILITY NUMBER:
197610509
ADMINISTRATOR:PODRUMYAN, MAROFACILITY TYPE:
740
ADDRESS:10012 SUNNYBRAE AVETELEPHONE:
(818) 632-2742
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:6CENSUS: 0DATE:
02/07/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:MARO PODRUMYAN - ADMINISTRATORTIME COMPLETED:
01:45 PM
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At 10:00am Licensing Program Analysts (LPAs), Angela Panushkina, Perchui Milena Khurshudyan and Licensing Program Manager (LPM) Nichelle Gillyard conducted an announced Pre-Licensing visit to the above facility and met with Administrator, Maro Podrumyan and Licensee Karine Karapetyan.

Fire Clearance was approved on 12/12/2023 for a maximum capacity of six (6) residents, of which four (4) Non-Ambulatory and one (1) bedridden residents in room #4. Facility was also approved for a Hospice waiver for six (6) residents on February 1st, 2024.

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. Today's site visit consisted of team touring the physical plant inside and outside and observed the following:

KITCHEN: The kitchen is equipped with a refrigerator, microwave oven and sink. At 10:30am, the team 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. Fire Extinguisher was last purchased on 10/31/23.


BEDROOMS: There are four (4) bedrooms designated for client use. Bedroom #4 was furnished with beds, dressers and required bedding and linen. The bedrooms have sufficient closet space and have sufficient lighting. Auditory alarms were tested and observed to be operational. Facility will have awake staff.

BATHROOMS: At 10:40am the team observed two and a half (2.5) bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured between 105°-106°F. observed appropriate grab bar and had non-skid mat. Continue on LIC809-C
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui KhurshudyanTELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024
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: KK SUNNYBRAE SENIOR LIVING
FACILITY NUMBER: 197610509
VISIT DATE: 02/07/2024
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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. The fireplace located in the dining room is adequately closed and inaccessible.

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

SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility. At 10:45am they were tested and observed to be operational.

SURROUNDING GROUNDS: In the back of the facility has sufficient yard space. The team observed appropriate outdoor furniture, with a covered shaded area for clients. The backyard is fenced. The team discussed the importance of maintaining the care and supervision to meet the needs of clients. There are no bodies of water.



GARAGE: The attached garage is currently being used for storage. The team observe the garage locked and inaccessible to residents in care. In addition, the team observed laundry room is located in the garage. The washer/dryer appear to be in good condition. Laundry supplies are kept inaccessible when not in use with supervision.

Component III was conducted with the Administrator and the Licensee.

Licensee was encouraged to sign up for sit alerts and guardian for future use and notifications. The Administrator was informed to notify the LPA regarding the first client/resident being admitted to the facility. The Administrator will also submit updated facility sketch indicating that the room #5 will be used for an Office/Staff room.

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 GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui KhurshudyanTELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024
LIC809 (FAS) - (06/04)
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