197610593-8-14-2024-31-AS-PKHN-D85S7F-20240814133728

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610593
Report Date: 08/14/2024
Date Signed: 08/14/2024 02:04:20 PM

Document Has Been Signed on 08/14/2024 02:04 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:	SENIORS LIVING HOME		FACILITY NUMBER:	197610593
ADMINISTRATOR:	HAKOBYAN VRAM		FACILITY TYPE:	740
ADDRESS:	10301 OSO AVENUE		TELEPHONE:	(818) 299-7501
CITY:	CHATSWORTH	STATE: CA	ZIP CODE:	91311
CAPACITY:	6	CENSUS: 0	DATE:	08/14/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:06 AM
MET WITH:	Hakobyan Vram-Administrator		TIME COMPLETED:	01:00 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	On 8/14/2024 at 10:00AM Licensing Program Analyst (LPA), Perchui Milena Khurshudyan conducted an announced Pre-Licensing visit to the above facility and met with facility Licensee/Administrator Hakobyan Vram. Fire Clearance was approved on 04/08/2024 for a maximum capacity of six (6) residents, of which four (4) can be Non-ambulatory and one (1) Bedridden resident. Facility has Dementia Care Program. 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. Today's site visit consisted of LPA touring the physical plant inside and outside and observed the following: KITCHEN: The facility has a Kitchen area that is equipped with a new refrigerator, microwave oven and sink. At 10:15AM, LPA observed adequate supplies of nonperishable food properly stored in the cabinets and inside the supply room. Perishable food items are not required at this time as there are no residents in the facility. Licensee will supply sufficient amount of perishable food upon arrival of the residents. LPA observed dining ware to accommodate a maximum capacity of six (6). All knives and sharps are observed to be locked in a kitchen cabinet and inaccessible to residents in care. The facility has one (1) new fire extinguisher, appeared to be full and serviced and were last purchased on 03/05/2024. BEDROOMS: There are five (5) bedrooms designated for residents use. All bedrooms are furnished with beds, dressers, chairs, night stands and required bedding and linen. The bedrooms have sufficient closet space and have sufficient lighting. Auditory alarms were tested and observed to be operational at 10:30AM.There is no bedroom designated for staff use. Facility will have awake staff at night. Emergency call buttons are available and will be provided to residents. Continue on LIC809C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui Khurshudyan	TELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

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 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: SENIORS LIVING HOME	FACILITY NUMBER: 197610593
	VISIT DATE: 08/14/2024

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

LAUNDRY ROOM: The laundry room is located in the garage, which is locked all the time. The washer/dryer appear to be new and in good condition. Laundry supplies along with other chemical items are kept locked inaccessible under supervision when not in use.

BATHROOMS: Facility has three (3) bathrooms. At 10:45AM LPA observed all bathrooms are clean, in good
repair and properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bars
and non-skid mats in all bathrooms. Trash cans had closed tight fitting lids throughout. Water temperature was
within regulation, and it was measured by an LPA at 10:45AM to be at 113°F degrees. Bathrooms #1 is designated for Staff and residents use.

COMMON AREAS: The facility maintains a comfortable temperature at 78°F. The living room and dining area
appeared clean and were properly furnished. The facility has separate activity room were puzzles, coloring books,
crayons, board games and other activity supplies are available. No obstructions and or tripping hazards throughout the facility. An emergency exit plan/sketch is posted along the hallway with other posting requirements. Facility has fireplace in the living room which is locked and safe for residents in care. No fire-arms observed or will be maintained on the premises.

MEDICATION ROOM: The medication will be centrally stored in the locked kitchen cabinet. Facility staff/resident files will be kept centrally stored and locked in the cabinet located next to the dining room. First-aid kit was checked to be complete and has the new manual available. Facility will have four (4) staff members, two (2) for each shift (AM and PM).

SMOKE DETECTORS/CARBON MONOXIDE. Dual smoke detectors and carbon monoxide were located in
the bedrooms and throughout the facility. At 11:00 AM they were tested and observed to be operational.

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: 08/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

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: SENIORS LIVING HOME	FACILITY NUMBER: 197610593
	VISIT DATE: 08/14/2024

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

SURROUNDING GROUNDS: The facility has gated entrance and sufficient yard space. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. The backyard is fenced. There is an attached garage which is currently being used for storage. LPA discussed the importance of maintaining the care and supervision to meet the needs of the residents. The property has properly fenced and locked pool, which is inaccessible to residents. The facility has land line located in the hallway area checked by an LPA to be operational.

Component III was conducted with the Administrator.

Based on inspection and observation, the physical plant is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) and the applicant 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 Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui Khurshudyan	TELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3