197610522-4-17-2024-31-AS-ADUA-D4EVAC-20240417161543

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610522
Report Date: 04/17/2024
Date Signed: 04/17/2024 04:15:50 PM

Document Has Been Signed on 04/17/2024 04:15 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:	VELORI SENIOR LIVING		FACILITY NUMBER:	197610522
ADMINISTRATOR:	DANIELYAN, RENA		FACILITY TYPE:	740
ADDRESS:	20414 KESWICK STREET		TELEPHONE:	(818) 934-7783
CITY:	WINNETKA	STATE: CA	ZIP CODE:	91306
CAPACITY:	6	CENSUS: 6	DATE:	04/17/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Irena Raskopina		TIME COMPLETED:	04:25 PM

NARRATIVE

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Licensing Program Analyst (LPA) Abeye Duguma conducted an announced Pre-licensing visit at around 11:15 AM and met with the Licensee, Irena Raskopina. LPA conducted an entrance interview with the Licensee. LPA Duguma also observed that there were six (06) residents in the facility during the inspection. All residents appear to be clean and groomed.

With the assistance of the Licensee, LPA conducted a facility tour of both the inside and outside. This is a single-story property. Fire Clearance is approved for six (06) non-ambulatory of which one (01) may be bedridden. Facility has five (05) bedrooms and three (03) full bathrooms for residents. One (01) out of five (05) bedrooms is semi-private and the remaining are all private single occupancy. All residents’ bedrooms were adequately furnished. The facility has a designated staff room/office with its own bathroom. Facility also has a half bath for visitors near the front entrance. Resident bathrooms have properly installed grab bars and shower has non-skid mats. The average hot water temperature measured at 115.5ºF during the visit.

The common areas were appropriately furnished. The LPA observed entertainment equipment and games for activities. The staff office has a designated storage cabinet for resident and staff records. The first-aid kit is complete. The facility has adequate linen, water, and emergency kits. The linens were stored in the storage space located in the hallway.

The facility has working egress alarms on all exits. Smoke detectors and carbon monoxide detectors were checked and function properly. There is a fully charged fire extinguisher located between the kitchen and dining area.

(CONT on LIC 9099-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
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: VELORI SENIOR LIVING	FACILITY NUMBER: 197610522
	VISIT DATE: 04/17/2024

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Receipt shows that fire extinguishers were purchased on 02/15/2024 and LPA advised the Licensee to retain the receipt of the fire extinguisher identifying the purchase date to ensure the time frame for annual inspection.

LPA Duguma observed a washer and dryer in the laundry area. All chemicals, additional personal hygiene items were stored in the locked cabinets. The medications are stored in a locked cabinet in the office.

LPA inspected the kitchen and observed stove and refrigerator to be clean and working. Knives and sharps are stored in a locked kitchen drawer.

There is sufficient outdoor space with seating and a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises.

At the time of this visit the physical plant is meeting Title 22 requirements.

Component III was completed with the LPA.

No health and safety hazard were noted during this visit.

Exit interview was conducted and a copy of report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
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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