197610532-4-15-2024-31-AS-TSMH-D4CQRU-20240415122431

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610532
Report Date: 04/15/2024
Date Signed: 04/15/2024 12:24:39 PM

Document Has Been Signed on 04/15/2024 12:24 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:	GOLDEN BLISS BOARD AND CARE		FACILITY NUMBER:	197610532
ADMINISTRATOR:	TERZYAN, NVART		FACILITY TYPE:	740
ADDRESS:	8609 AQUEDUCT AVE		TELEPHONE:	(818) 697-3926
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY:	6	CENSUS: 0	DATE:	04/15/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Marianna Ghazaryan		TIME COMPLETED:	12:30 PM

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At 10:10 am Licensing Program Analyst (LPA) Tihesha Smith conducted an announced pre-licensing visit with the licensee and administrator. Identification of the Licensee and administrator was verified by photo ID.The facility has a capacity of six (6). Application received for 1 bedridden and (5) Non-ambulatory residents.

Purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with the rules and regulations of California Code of Regulations, Title 22, Division 6. The facility is a single-story building. Today's site visit consisted of LPA touring the physical plant inside and outside and observed the following:

The common areas (kitchen, living room, and dining areas) were appropriately furnished, and lighting was adequate. The facility has a variety of adequate perishable and non-perishable food supply. Appliances in the kitchen appeared to be functional. The living room has a television and comfortable furniture. Games and activities for residents stored in coffee table.

There is one (1) fire extinguishers: one (1) is located in garage attached to kitchen/dining room wall and observed to be fully charged with receipt Dec 2023. Dual Smoke and Carbon Monoxide detectors were observed all over the facility, tested, and observed to be operational at time of visit.

An emergency exit plan/sketch is posted near each entrance/exit wall with other posting requirements.

There are two (2) bathrooms in the facility. The Hot water was tested for resident bathroom and measured 115.9 and 117.1 °F. Bathrooms has trash cans with lids and bathroom has functional grab bars.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024

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: GOLDEN BLISS BOARD AND CARE	FACILITY NUMBER: 197610532
	VISIT DATE: 04/15/2024

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(Cont from 809)
There are three (3) resident bedrooms, designated as follows:

B1: Non ambulatory/Shared B2: Non-Ambulatory/Shared

B3 Non-Ambulatory and Bedridden/shared No room is designated for staff use.

Extra linen stored in living room Television console and each bedroom has own linen storage in closet

The sharps are stored and locked in drawer in kitchen. Medications locked in upper kitchen cabinet. Toxins locked under kitchen sink. The first aid kit is stored in kitchen counter. Laundry is in hall closet and appliances observed to be in good repair.

There is a large patio table with six (6) chairs, and umbrella for residents to conduct outdoor activities.

The garage is detached

There is no body of water on the facility.

Component III was conducted with the administrator and licensee. Both individuals confirmed understanding of Title 22.

At time of visit this facility is not ready to be licensed. The following corrections must be made:

· Install functioning telephone/landline on the premises.

· Remove personal items from garage or designate not part of the facility

· Water and Electric not listed correctly on facility sketch

· Submit new sketch with corrections made.

This report will be forwarded to the Centralized Application Bureau (CAB).

Exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024

LIC809 (FAS) - (06/04)

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