197610563-4-19-2024-31-AS-PKHN-D4GQFM-20240419120809

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610563
Report Date: 04/19/2024
Date Signed: 04/19/2024 12:09:54 PM

Document Has Been Signed on 04/19/2024 12:09 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:	A-1 ASCENDED SENIOR CARE 3		FACILITY NUMBER:	197610563
ADMINISTRATOR:	PARTRIDGE, BRUCE R.		FACILITY TYPE:	740
ADDRESS:	20022 VINTAGE STREET		TELEPHONE:	(818) 268-6707
CITY:	CHATSWORTH	STATE: CA	ZIP CODE:	91311
CAPACITY:	6	CENSUS: 0	DATE:	04/19/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	PARTRIDGE BRUCE-ADMINISTRATOR		TIME COMPLETED:	01:15 PM

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	At 10:30am, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted an announced Pre-Licensing Inspection at this facility, met with Licensee Aida Manukyan and Administrator Bruce R. Partridge. 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. Today's site visit consisted of touring the physical plant inside and outside. A tour of the physical plant was initiated at 10:40am and the following was observed: Fire Clearance was approved on 01/29/2024 for a maximum capacity of six (6) residents, of which six (6) Non-Ambulatory, six (6) may be Bedridden and Hospice waiver granted for six (6). The facility currently has no residents, but plans on operating at full capacity six (6). The facility is a one story building with six (6) bedrooms and three (3) bathrooms. KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven and sink. There were adequate supply of 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. BEDROOMS: There are six (6) bedrooms designated for residents’ use. All six bedrooms are designated for private use. Currently, Room #2 is used as the model bedroom. Room #3 was equipped with bed, nightstand, chair, dresser bedding and linen. Rooms #1, #3, #4, #5 and #6 were not furnished at this time. Rooms were observed to have sufficient lighting and closet space. Per STD 850, all six (6) bedrooms are cleared for Bedridden residents. Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui Khurshudyan	TELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024

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: A-1 ASCENDED SENIOR CARE 3	FACILITY NUMBER: 197610563
	VISIT DATE: 04/19/2024

NARRATIVE

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BATHROOMS: At 10:50am LPA observed three (3) bathrooms are clean and in good repair. Properly supplied with toilet papers, soap, and paper towels. The hot water temperature measured 120°F. Bathrooms observed to have appropriate grab bar and non-skid mat. Bathroom #1 is located in the hallway beside bedrooms #3 and #4. Bathroom #2 is located inside bedroom #2 for private use. Bathroom #3 is located beside bedroom #6.

MEDICATION: The medications will be kept in the separate area in the dining room and LPA observed the cabinet kept locked and inaccessible to residents in care.

COMMON AREAS: The facility maintains a comfortable temperature at 71°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 living room and dining room is adequately closed and inaccessible.

SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility. At 10:55am they were tested and observed to be operational.

FIRE EXTINGUISHER was last purchased on 4/15/2024 is located in the kitchen and 2^nd one is located in the garage. First-aid is complete and new.

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. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients. There are no bodies of water.

Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui Khurshudyan	TELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024

LIC809 (FAS) - (06/04)

Page: 2 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: A-1 ASCENDED SENIOR CARE 3	FACILITY NUMBER: 197610563
	VISIT DATE: 04/19/2024

NARRATIVE

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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.

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

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 Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui Khurshudyan	TELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024

LIC809 (FAS) - (06/04)

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