197610600-6-19-2024-31-AS-APAA-D6DQCH-20240619120310

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610600
Report Date: 06/19/2024
Date Signed: 06/19/2024 12:04:05 PM

Document Has Been Signed on 06/19/2024 12:04 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	AGAPE SENIOR RESIDENCE		FACILITY NUMBER:	197610600
ADMINISTRATOR:	ANAHIT OHANYAN		FACILITY TYPE:	740
ADDRESS:	9746 QUARTZ AVE		TELEPHONE:	(818) 796-9146
CITY:	CHATSWORTH	STATE: CA	ZIP CODE:	91311
CAPACITY:	6	CENSUS: 0	DATE:	06/19/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Anahit Ohanyan, Administrator		TIME COMPLETED:	12:30 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 10:00am Licensing Program Analyst (LPA) Angela Panushkina conducted an announced Pre-Licensing visit to the above facility and met with Administrator, Anahit Ohanyan. Fire Clearance approved on 05/02/2024 for the total capacity of six (6) residents, of which five (5) can be Non-ambulatory and one (1) bedridden in room #1 Facility was also approved for a Hospice waiver for five (5) 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 10:15am, LPA will have 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 03/22/24. BEDROOMS: There are four (4) bedrooms designated for client use. 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 10:20am the LPA observed 2½ bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured between 112F. observed appropriate grab bar and had non-skid mat. COMMON AREAS: The facility maintains a comfortable temperature at 76°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 was observed adequately closed and inaccessible to residents in care. Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AGAPE SENIOR RESIDENCE	FACILITY NUMBER: 197610600
	VISIT DATE: 06/19/2024

NARRATIVE

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MEDICATION: The medications will be kept in the kitchen cabinet and LPA 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 10:30am they were tested and observed to be operational. SURROUNDING GROUNDS: In the back of the facility has sufficient yard space. LPA 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. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents. GARAGE: The attached garage is currently being used for storage. LPA observed the garage locked and inaccessible to residents in care. Laundry area is located by the garage and LPA observed the washer/dryer appear to be in good condition and all 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) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

LIC809 (FAS) - (06/04)

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