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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610554
Report Date: 05/31/2024
Date Signed: 05/31/2024 02:20:01 PM


Document Has Been Signed on 05/31/2024 02:20 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:OTRIUM CARE HOMESFACILITY NUMBER:
197610554
ADMINISTRATOR:SAHAKYAN, DAVIDFACILITY TYPE:
740
ADDRESS:15933 RAYEN STREETTELEPHONE:
(310) 404-3778
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 0DATE:
05/31/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:03 AM
MET WITH:David Sahakyan-Licensee/AdministratorTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted an announced Pre-Licensing Inspection with the Licensee/administrator, David Sahakyan.

A fire clearance was approved on 04/12/2024 for five (5) non-ambulatory residents and one (1) bedridden resident, for a total capacity of six (6). The applicant is also requesting a hospice waiver to retain six (6) residents. LPA observed no residents during the inspection.

With the assistance of the Licensee/administrator, LPA conducted a tour of both the inside and outside of the facility. This is a single-story property with four (4) bedrooms and two and a half (2.5) bathrooms. The smoke alarms and carbon monoxide detectors are dual and hard wired. At 11:15am they were tested and observed to be operational. The facility has one new fire extinguisher that was purchased on May 30th, 2024 and It is located in the living room.
A tour of the physical plant was initiated at approximately 10:15am and the following was observed:

Kitchen: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven, dish washer and sink. The kitchen appliances and fixtures were functional. LPAs found a sufficient amount of non-perishable food at the facility; properly stored. Perishable food items are not required at this time as there are no residents in the facility. LPA observed dining ware to accommodate a maximum capacity of six (6). Knives and sharps will be stored in a locked cabinet inside the kitchen.

Bedrooms: There are four (4) bedrooms designated for residents’ use. Bedrooms #2 and #4 are private, while bedrooms #1 and #3 are shared. Per Fire clearance, bedroom #4 only has the fire clearance for bedridden. The licensee furnished all the resident bedrooms with beds, night stand, chairs, dresser, bedding and linen. The bedrooms also have sufficient lighting and closet space.
Continue on LIC809-C
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui KhurshudyanTELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


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: OTRIUM CARE HOMES
FACILITY NUMBER: 197610554
VISIT DATE: 05/31/2024
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Bathrooms: The facility has two and a half (2.5) bathrooms. Bedroom #1 has it's own bathroom. All bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The half bathroom water The hot water delivered in the bathrooms measured at 115 degrees.

Common Areas: These included the living room which were equipped with a couch, chair, television, and table. There is a fireplace with a screen but will be non-operational. No fireplace tools or fixtures present. The dining area has a large dining room table to accommodate between six (6) to eight (8) people. There were no visible immediate hazards.



Medications: The medication cabinet is located in the office are next to the kitchen. Cabinet has a locking mechanism to ensure medications will be inaccessible to residents in care.

Garage: Door to the garage has an alert to notify staff that the entry door to the garage is open. No cleaning supplies observed or will be kept in the garage. Garage will also be used as extra storage space for equipment, PPE supplies, and emergency water.

OFFICE/STAFF WORKSTATION: Staff workstation is located by the entrance next to the kitchen. Resident and personnel files will be maintained in a locked filing cabinet there.

Laundry Room: The laundry room is located next to the kitchen area locked and inaccessible to residents in care. The washer/dryer appeared brand new. Laundry supplies will also be kept inaccessible inside the laundry room.

Continue on LIC809-C

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

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
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: OTRIUM CARE HOMES
FACILITY NUMBER: 197610554
VISIT DATE: 05/31/2024
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Surrounding Areas: 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 backyard of the facility has a patio and backyard furniture to accommodate the six (6) residents. The facility backyard has sufficient yard space. There is no swimming pool or bodies of water.
Facility has land-line, LPA checked its operational.

In addition to the Pre-Licensing inspection, a Component III power point presentation was also held between/approximately 12:30pm and 1:30pm.

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 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: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3