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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198202959
Report Date: 11/22/2021
Date Signed: 11/22/2021 10:57:12 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:MOONLIGHT GARDEN RESIDENTIAL FACILITY FOR ELDERLYFACILITY NUMBER:
198202959
ADMINISTRATOR:MOZHGAN MOJABFACILITY TYPE:
740
ADDRESS:3670 BARRY AVE.TELEPHONE:
(310) 621-4595
CITY:LOS ANGELESSTATE: CAZIP CODE:
90066
CAPACITY:6CENSUS: DATE:
11/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:52 AM
MET WITH:Mozhgan MojabTIME COMPLETED:
12:03 AM
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On 11/22/2021, Licensing Program Analyst (LPA) Ngozi Nwaokoro conducted an unannounced visit to Moonlight Garden Residential Facility for Elderly. The purpose of today’s visit was to conduct the annual inspection, with emphasis on infection Control. LPA met with the Licensee, Mozhgan Mojab. Facility is licensed for 6 non-ambulatory residents. The facility currently has zero (0) residents residing at the facility.

LPA toured the physical plant and ensured that there were no residents residing in the facility. The home consists of 4 bedrooms, 4 bathrooms, living room, dining room, and kitchen. Bedrooms had the required furniture, bed linens and closet/drawer space to accommodate residents. Bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew. Water temperature properly measured between 105 – 120 degrees Fahrenheit. Bath towels and toiletries were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. All doors have auditory alarms.

Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. Cleaning solutions and hazardous items were placed in cabinets. Smoke detectors were working properly. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

No deficiencies cited during this visit.

Exit interview conducted and a copy of this report was given to Mozhgan Mojab.

SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Ngozi NwaokoroTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
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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