197610519-4-17-2024-31-AS-MCAA-D4EQ5Y-20240417115244

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610519
Report Date: 04/17/2024
Date Signed: 04/17/2024 11:52:56 AM

Document Has Been Signed on 04/17/2024 11:52 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	FUTURE SENIOR LIVING		FACILITY NUMBER:	197610519
ADMINISTRATOR:	BERBERYAN, NELLI		FACILITY TYPE:	740
ADDRESS:	12303 MCLENNAN AVE		TELEPHONE:	(323) 383-7738
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	6	CENSUS: 0	DATE:	04/17/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Nelli Berberyan		TIME COMPLETED:	11:55 AM

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 administrator Nelli Berberyan. An Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on October 5, 2023. A fire clearance was approved on March 22, 2024 for six (6) non-ambulatory for a total capacity of six. The applicant is also requesting a hospice waiver to retain six (6) residents. The smoke alarms and carbon monoxide detector are dual, hard wired and inter-connected. The facility has one new fire extinguishers that was purchased on April 15, 2024. The fire extinguisher is located by the kitchen. A tour of the physical plant was initiated at approximately 9:15am and the following was observed: KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven and sink. There were adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). Knives were observed locked in a kitchen drawer. In addition to the non-perishable (canned foods), the applicant has two buckets of an emergency food supply, good for about twenty years. BEDROOMS: There are four (4) bedrooms designated for client use. Bedroom #1 and #4 are shared rooms, Bedrooms #2 and #3 are private rooms. The applicant furnished the resident bedrooms with beds, night stand, chairs, dresser, bedding and linen. The bedrooms have sufficient lighting and closet space. BATHROOMS: The facility has three (3) bathrooms. Bedroom #4 has it's own bathroom. One bathroom is located in the hallway, across from bedroom #1 is for staff and visitors only. Another bathroom, reserved for the resident's use, is located in the hallway, across from bedroom #3. The bathrooms reserved for resident's use were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured at 105 degrees.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

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: FUTURE SENIOR LIVING	FACILITY NUMBER: 197610519
	VISIT DATE: 04/17/2024

NARRATIVE

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COMMON AREAS: These included the livint room/ tv, activity room, and dining room. The living room is observed with brand new furniture (couches and table), and a television. There is no fireplace with a screen and a glass slide. The activity room is located adjacent to the dining area. Chairs, tables, ping pong table and sufficient board games were observed. The dining area has a large dining room table to accommodate six (6). There were no visible immediate hazards.

LAUNDRY ROOM: The laundry room is located by the garage. It was observed with a locked door requiring a key to gain access. The washer/dryer are brand new.

MEDICATIONS: The medication cabinet is located in the kitchen. It has a locking mechanism. First aid kit and first aid manual is also maintained there.

OFFICE/STAFF WORKSTATION: Staff workstation is located at the corner of the activity room. Resident and personnel files will be maintained in a locked filing cabinet there.

GARAGE: The garage is attached to the building, located adjacent to the laundry room. It is used as extra storage space. No resident access there as there is a locked door to gain entry through the laundry room, to get to the garage.

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 left side of the home and backyard of the facility has no access to the residents. There is an ADU on the left side of the facility, that has it's own private entrance, leaving no accessibility to the residents. The exterior, right side of the facility is for resident use only. It was observed with outdoor furniture and has sufficient yard space.

In addition to the Pre-Licensing inspection, a Component III power point presentation was held.

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: 04/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

LIC809 (FAS) - (06/04)

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