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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610587
Report Date: 06/14/2024
Date Signed: 06/14/2024 11:59:02 AM


Document Has Been Signed on 06/14/2024 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:ASSISTED LIVING ON GLADE LLCFACILITY NUMBER:
197610587
ADMINISTRATOR:GEVORKYAN, SONAFACILITY TYPE:
740
ADDRESS:10140 GLADE AVETELEPHONE:
(818) 696-3110
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:6CENSUS: 0DATE:
06/14/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Sona Gevorkyan-AdministratorTIME COMPLETED:
12:30 PM
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At 9:30am Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted an announced Pre-Licensing Inspection and met with the facility administrator Sona Gevorkyan and Licensee Sipan Movsesyan.

An application was submitted to Community Care Licensing Division-CCLD on 02/20/2024, Initial license for a Residential Care Facility for the Elderly, 60 years and older. A fire clearance was approved on May 21, 2024 for five (5) non-ambulatory residents and one (1) bedridden resident, for a total capacity of six (6). The bedridden fire clearance is for bedrooms #5. Bedrooms #1, #2, #3, and #4, cleared for non-ambulatory residents. Bedroom #6 is cleared for ambulatory resident only. The Licensee also requested a hospice waiver and granted for six (6) residents. The facility is a single-story home.
With the assistance of the Licensee/administrator, a tour of the physical plant was initiated at approximately 10:00am 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. LPA 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) residents. Knives and sharps will be stored in a locked cabinet inside the kitchen. Kitchen chemicals are stored in the separate locket closet.

BEDROOMS: There are six (6) bedrooms designated for residents’ use. All bedrooms are furnished and well equipped with beds, nightstand, chair, dresser, bedding, and extra linen. Rooms were observed to have sufficient lighting and closet space. Auditory alarms were tested and observed to be operational at 10:15am. Facility will have awake staff. Emergency call buttons/bells are available and will be provided to residents.
Continue on LIC809C
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui KhurshudyanTELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024
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 2


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: ASSISTED LIVING ON GLADE LLC
FACILITY NUMBER: 197610587
VISIT DATE: 06/14/2024
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BATHROOMS: The facility has two (2) bathrooms, bathroom #1 is located inside bedroom #1, bathroom #2 is located in the hallway next to the bedrooms #2 and #4, and designated for both residents and staff. Both bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured at 10:20am to be at 110°F degrees.

MEDICATION: LPA observed medication, facility staff/resident files, and First Aid kit will be kept locked in the separate storage room inside the locked cabinet and inaccessible to residents in care. LPA observed First-aid kit is complete and has new manual. Facility has Dementia Care Program.

SMOKE DETECTORS/CARBON MONOXIDE. The smoke detectors and carbon monoxide are hard wired, inter-connected and were located throughout the facility. At 11:00am they were tested and observed to be operational. The facility has one (1) new fire extinguishers that was purchased on May 14th, 2024. The fire extinguisher is located in the kitchen.

COMMON AREAS: The facility maintains a comfortable temperature at 74°F. The living room and dining appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. LPA observed puzzles, books, balls, and board games to provide activities to residents in care. Living room has fire place, which is blocked with TV stand. Facility has land line, LPA checked its operational.

SURROUNDING GROUNDS: In the back of the facility has sufficient yard space. LPA observed appropriate outdoor furniture, with covered shaded area for residents. 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.

GARAGE: The garage is currently being used for storage. The LPA observed 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.

Component III 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 will be notified by the CAB Analyst when the 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: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024
LIC809 (FAS) - (06/04)
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