197610602-6-17-2024-31-AS-APAA-D6BQGJ-20240617120938

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610602
Report Date: 06/17/2024
Date Signed: 06/17/2024 12:10:03 PM

Document Has Been Signed on 06/17/2024 12:10 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:	MAYALL ASSISTED LIVING		FACILITY NUMBER:	197610602
ADMINISTRATOR:	DISHOYAN, ARMINE		FACILITY TYPE:	740
ADDRESS:	20507 MAYALL STREET		TELEPHONE:	(818) 809-8559
CITY:	CHATSWORTH	STATE: CA	ZIP CODE:	91311
CAPACITY:	6	CENSUS: 0	DATE:	06/17/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Armine Dishoyan, Administrator		TIME COMPLETED:	12:30 PM

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At 09:30am, Licensing Program Analyst (LPA) Angela Panushkina conducted an announced pre-licensing visit with the facility Owner - Seda Smbatyan and the Administrator - Armine Dishoyan.

The facility has a capacity of six (6). Application was received for six (6) total residents, one (1) Ambulatory, four (4) Non-ambulatory and one (1) may be Bedridden in room #2.

Purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with the rules and regulations of California Code of Regulations, Title 22, Division 6. 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:

At 9:40am, LPA toured the common areas (living room, kitchen, and dining areas) were appropriately furnished and lighting was adequate. There is a functioning telephone/land line on the premises. The living room has a television and comfortable furniture. LPA observed fireplace adequately screened. An emergency exit plan/sketch is posted upon entry, in the kitchen and hallways.

The sharps are stored and locked in the kitchen drawer. The facility has a variety of adequate perishable and non-perishable food supply. Appliances in the kitchen appeared to be functional. At 10:00am, LPA observed the fire extinguisher was last purchased on 04/16/24 and fully charged.

At 10:10am, LPA observed all cleaning supplies, laundry detergents, and other toxins are stored in a laundry room and kept locked and inaccessible to residents in care. The necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on all entry/exit doors.

There are four (4) bedrooms designated for residents use. Resident bedrooms were observed to be appropriately furnished with a bed, night stand, a chair, and extra linens. Facility will have awake staff at night. Facility appears to be clean and in good repair. 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: 06/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024

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: MAYALL ASSISTED LIVING	FACILITY NUMBER: 197610602
	VISIT DATE: 06/17/2024

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There are 2½ bathrooms in the facility and all bathrooms have non-skid mats, trash cans with lids and functional grab bars. Hot water was tested in the bathroom and measured at approximately 116.0°F

The back of the facility has sufficient yard space. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water.

Component III was conducted with the Owner and Administrator

Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.

Exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024

LIC809 (FAS) - (06/04)

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