197610581-5-2-2024-31-AS-HRAI-D4VPKK-20240502112316

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610581
Report Date: 05/02/2024
Date Signed: 05/02/2024 11:24:02 AM

Document Has Been Signed on 05/02/2024 11:24 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:	COVELLO HOMES		FACILITY NUMBER:	197610581
ADMINISTRATOR:	VARDAN BAGHDASARYAN		FACILITY TYPE:	740
ADDRESS:	18807 COVELLO STREET		TELEPHONE:	(818) 279-1415
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY:	6	CENSUS: 2	DATE:	05/02/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Vardan Baghdasaryan, Administrator		TIME COMPLETED:	11:45 AM

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 9:00 am, Licensing Program Analyst (LPA), Huma Rahimi conducted an announced Pre-Licensing visit to the above facility and met with Administrator. LPA conducted an entrance interview with the Administrator. At the time of this visit LPA did not observe any residents present in the facility. Fire Clearance dated 02/27/2024 and received for six (6) Bedridden 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. The facility is a single-story building. LPA toured the physical plant inside and outside and observed the following:

KITCHEN: At 9:15 LPA toured the kitchen. The kitchen area is equipped with a refrigerator, microwave oven, sink. Stove was observed in a good working condition. LPA observed adequate supplies of nonperishable food and dining ware to accommodate a maximum capacity of six (6). All knives and sharps are observed to be locked in the kitchen in a cabinet. Chemicals and toxins were locked under the sink and inaccessible to residents.

BEDROOMS: At 9:22 AM, LPA observed tha the facility has six (6) bedrooms of which five (5) bedrooms are for resident’s use and one (1) designated for staff which will be locked and inaccessible to clients. Bedroom # one (1), bedroom # two (2), bedroom # three (3), and bedroom # five (5) are private. Bedroom # four (4) is shared. Bedroom # one (1) and bedroom # two (2) were occupied. LPA observed all bedrooms properly furnished with beds, dressers and required bedding, chest drawer, and linen. The bedrooms have sufficient closet space and have sufficient lighting. Facility will have a live-in staff at the facility. LPA did not observe any obstruction or hazard.

Continue on LIC 809C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024

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: COVELLO HOMES	FACILITY NUMBER: 197610581
	VISIT DATE: 05/02/2024

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
26
27
28
29
30
31
32

BATHROOMS: At 9:23 AM, LPA observed three (3) bathrooms. There are two (2) private bathrooms in bedroom # one (1) and bedroom # four (4). The shared bathroom is in the hall by bedroom # two (2) and bedroom # three (3). All bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed to have an appropriate non-skid mat. At 9:25 AM, the water temperature was noted at 120°.

COMMON AREAS: LPA observed all common area to be clean in good repair. The facility maintains a comfortable temperature at 72°F. The living room and dining rooms were properly furnished. No obstructions and or tripping hazards throughout the facility. The living room has a screened fireplace. There is a dinning table which can accommodate six (6) residents.

MEDICATION: Facility has a separate locked refrigerator for resident’s medication. The fridge is located in the dining room behind the dining table. Medications that do not require refrigeration will be kept in the locked cabinet by the kitchen. LPA observed two additional locked cabinets for staff and resident’s files as well as additional over the counter medications in the dining room.

LAUNDRY ROOM: The laundry room is in the garage. LPA observed the washer and dryer are in good repair. The garage has a locked cabinet where the laundry detergents are locked and inaccessible to residents in care. The garage is used as a storage for equipment, emergency supply, and water.

SURROUNDING GROUNDS: The facility has a backyard and has sufficient space. LPA observe appropriate outdoor furniture, and a covered shaded area for clients. There is no swimming pool or any bodies of water at the facility. The facility has one emergency exit and LPA observed to be free of hazard.

SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility. At 9:40 AM, they were tested and observed to be operational. At 9:45 AM, LPA observed a full Fire Extinguisher hanging next to the kitchen wall and was last serviced on 07/11/2023.

Continue on LIC 809C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024

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: COVELLO HOMES	FACILITY NUMBER: 197610581
	VISIT DATE: 05/02/2024

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
26
27
28
29
30
31
32

Between 10:30 AM, to 11:10 am, LPA reviewed records of two (2) residents and one (1) staff. LPA observed that resident # 1 (R1) file was under the new or to be facility’s name. Administrator agreed to change the file under the current facility’s name and number.
Once the Administrator submit the file change, LPA will inform CAB Analyst for license approval.

Component III was conducted with the Administrator.

Pursuant to Title 22, the facility is compliant to regulation, is not ready for licensure. This report will be forwarded to the Centralized Application Bureau (CAB). The applicant will be notified by the CAB Analyst when their license is approved.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3