198603493-12-15-2021-28-AS-MGFS-C9R24X-20211215160440

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603493
Report Date: 12/15/2021
Date Signed: 12/15/2021 04:04:48 PM

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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	MOON LIGHT BOARDING CARE INC		FACILITY NUMBER:	198603493
ADMINISTRATOR:	PETROSYAN, ANNA		FACILITY TYPE:	740
ADDRESS:	120 SIERRA BONITA AVE		TELEPHONE:	(818) 661-7333
CITY:	PASADENA	STATE: CA	ZIP CODE:	91106
CAPACITY:	6	CENSUS: 0	DATE:	12/15/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:42 PM
MET WITH:	Anna Petrosyan - Applicant		TIME COMPLETED:	04:20 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	Licensing Program Analyst(s) (LPA) Mary Flores and Jewel Baptiste conducted an announced pre-licensing visit. LPAs met with Anna Petrosyan applicant and Sako Manvelyan applicant and explain the reason for the visit. The facility was approved by the Fire Department on 5/28/21 for 5 non-ambulatory and 1 bedridden residents over the age of 60 years old with a hospice waiver for 4. Facility will be serving dementia residents. Facility consist of a dinning room, living room, a kitchen, 4 bedrooms, 5 bathrooms, a front yard, a back yard, basement/laundry area and a detached garage. LPAs conducted a tour of the facility with Anna Petrosyan applicant and Sako Manvelyan applicant: Kitchen: Dishes were observed sufficient for 6 residents. Knives and sharps locked on a drawer next to medication refrigerator. Refrigerator temperature was read at 36 degrees F and freezer's temperature read at Lowest level. Medication cabinet with key card lock located to the left of refrigerator. Non-perishables foods such as vegetables, fruits, and beans were stored in the detached garage. Bedrooms: Bedrooms #1 and #2 had beds with all required bedding. Bedroom #1, #2,#3,#4 have a chair per resident, a chest drawer, and closet space. Sufficient lighting in each room. Bedroom #3 and #4 will be fully furnish by the residents per applicant. Bathrooms: Bathroom #1(B1),#4(B4),#5(B5) have all grab bars and skid mats. Bathroom #2(B2) is a half bad with toilet grab bar and #3(B3) is a full bath per applicant shower tub will not be used for resident's care and does not have grab bars, toilet has a grab bar. Water temperature tested as follow B1 at 122 degrees F, B2 at 121.6 degrees F, B3 at 109 degrees F, B4 at 95 degrees F, and B5 at 89.9 degrees F, which is within the required 105 - 120 degrees F.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021

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 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MOON LIGHT BOARDING CARE INC	FACILITY NUMBER: 198603493
	VISIT DATE: 12/15/2021

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

Smoke detectors were interlaced and tested and in working condition. Carbon monoxide was observed in hallway by the kitchen. Fire extinguisher is located on the wall outside the kitchen. Sound device was observed in each exit door and in working condition. Upstairs office, Basement and Garage are inaccessible to the residents and will be kept locked at all times.
No large bodies of water were observed. Outdoor shaded area will be provided in the back yard. First Aid Kit was observed and has a tweezers, scissors, antiseptic, bandages, gauze and thermometer. The following PPE supplies were observed gloves, surgical mask, disinfectant spray.

LPAs reviewed Component III with applicants.

The following items need to be corrected and proof of correction needs to be submitted to licensing within 7 days:

Applicant will set up purchased shaded sitting area in backyard.
Applicant will stored additional blankets for residents.
Applicant will maintain First Aid Safety Handbook.
Applicant will maintain N95 mask and faceshields at facility.
Applicant will ensure water temperature is within the required 105 - 120 degrees F and will maintain a log for the next 7 days.

Exit interview was conducted with Anna Petrosyan applicant and a copy of this report was provided.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021

LIC809 (FAS) - (06/04)

Page: 2 of 2