197610566-4-12-2024-31-AS-PKHN-D49Q94-20240412115745

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610566
Report Date: 04/12/2024
Date Signed: 04/12/2024 11:59:47 AM

Document Has Been Signed on 04/12/2024 11:59 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	A-1 ASCENDED SENIOR CARE 2		FACILITY NUMBER:	197610566
ADMINISTRATOR:	TOPCHYAN, HARUT		FACILITY TYPE:	740
ADDRESS:	19911 VINTAGE STREET		TELEPHONE:	(818) 667-4915
CITY:	CHATSWORTH	STATE: CA	ZIP CODE:	91311
CAPACITY:	6	CENSUS: 0	DATE:	04/12/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Harut Topchyan - Administrator		TIME COMPLETED:	12:20 PM

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At 10:00am Licensing Program Analysts (LPAs) Perchui Milena Khurshudyan and Angela Panushkina conducted an announced Pre-Licensing visit to the above facility and met with Administrator, Harut Topchyan.

Fire Clearance was approved on 1/29/2024 for a maximum capacity of six (6) bedridden residents, Facility was also approved for a Hospice waiver for six (6) residents.

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. The facility is a single-story building. Today's site visit consisted of team touring the physical plant inside and outside and observed the following:

KITCHEN: The kitchen is equipped with a refrigerator, microwave oven and sink. At 10:150am, LPAs observed adequate supplies of perishable and 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. Fire Extinguisher was last serviced on 04/06/23.

BEDROOMS: There are six (6) bedrooms designated for client use. Bedroom #4 was furnished with bed, dressers and required bedding and linen. The bedrooms have sufficient closet space and have sufficient lighting. Auditory alarms were tested and observed to be operational. Facility will have awake staff.

BATHROOMS: At 10:30am the team observed three and a half (3.5) bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured between 120F. observed appropriate grab bar and had non-skid mat.

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: 04/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024

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 2	FACILITY NUMBER: 197610566
	VISIT DATE: 04/12/2024

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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 dining room is adequately closed and inaccessible.

MEDICATION: The medications will be kept in the kitchen cabinet and LPAs observed the cabinet kept locked and inaccessible to residents in care.

SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility. At 11:00am they were tested and observed to be operational.

SURROUNDING GROUNDS: In the back of the facility has sufficient yard space. LPAs observed appropriate outdoor furniture, with a covered shaded area for clients. There is a pool in the backyard which is fenced and has proper locking system. LPAs discussed the importance of maintaining the care and supervision to meet the needs of clients. There are no bodies of water.

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 in a separate locked area before entering the garage. The washer/dryer appear to be in good condition. Laundry supplies are kept inaccessible when not in use with supervision.

Component III was conducted with the Administrator.

Licensee was encouraged to sign up for sit alerts and guardian for future use and notifications. The Administrator was informed to notify the LPA regarding the first client/resident being admitted to the facility.

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: 04/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024

LIC809 (FAS) - (06/04)

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