197610620-8-21-2024-31-AS-RVAA-D8CT86-20240821142949

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610620
Report Date: 08/21/2024
Date Signed: 08/21/2024 02:30:27 PM

Document Has Been Signed on 08/21/2024 02:30 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:	FAIRWAY ASSISTED LIVING		FACILITY NUMBER:	197610620
ADMINISTRATOR:	MURADYAN, SEDA		FACILITY TYPE:	740
ADDRESS:	2623 FAIRWAY AVE		TELEPHONE:	(818) 601-7839
CITY:	MONTROSE	STATE: CA	ZIP CODE:	91020
CAPACITY:	6	CENSUS: 0	DATE:	08/21/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Seda Muradyan, Administrator		TIME COMPLETED:	03:30 PM

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At 10:30am, Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an announced Pre-Licensing visit to this facility and met with the Administrator. This is an initial application. The purpose of today’s visit is to inspect the facility to ensure that it maintains compliance under California Code of Regulations, Title 22, Division 6.

Today’s site visit consisted of LPA touring the physical plant inside and outside and observed the following:

Facility Fire clearance was conducted on 06/11/2024 and approved for five (05) non- ambulatory residents and one (01) bedridden resident . The facility has dual carbon monoxide and smoke alarm system. There is a fire extinguisher located in the kitchen with a date of purchase of 03/2024. There will be a functioning telephone on the premises. An emergency exit plan/sketch is posted in each bedroom and in the hallway wall with other posting requirements. There are three (03) bedrooms designated for residents use. Residents bedrooms were observed to be appropriately furnished. There are three (03) bathrooms in the facility. Bathrooms have non-skid mats and appropriate grab bars. Trash cans were observed to have closed tight fitting lids.

The common areas (living room, kitchen, and dining areas) were appropriately furnished, and lighting was adequate. The living room has a television and comfortable furniture. Resident, staff records and medication will be stored in a locked cabinet in the dinning room. There is one (01) first aid kit.

The kitchen knives are stored in a locked drawer. Cleaning supplies and toxic chemicals are stored in a locked cabinet underneath the kitchen sink. Laundry detergents, cleaning supplies and other toxins are stored in the garage. LPA observed the garage to be locked and inaccessible to residents in care. Facility appears to be clean and in good repair. Appliances in the kitchen are new and functional.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: FAIRWAY ASSISTED LIVING	FACILITY NUMBER: 197610620
	VISIT DATE: 08/21/2024

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There will be a sitting area in the backyard for residents to conduct outdoor activities. The outdoor, front and back yards were free of any obstruction. There is no body of water.

Component III was conducted with applicant.

No deficiencies issued with this report. 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. A copy of this report was signed and delivered.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

LIC809 (FAS) - (06/04)

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