<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603493
Report Date: 01/26/2022
Date Signed: 01/26/2022 09:44:30 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MOON LIGHT BOARDING CARE INCFACILITY NUMBER:
198603493
ADMINISTRATOR:PETROSYAN, ANNAFACILITY TYPE:
740
ADDRESS:120 SIERRA BONITA AVETELEPHONE:
(818) 661-7333
CITY:PASADENASTATE: CAZIP CODE:
91106
CAPACITY:6CENSUS: 0DATE:
01/26/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Sako Manvelyan - Applicant TIME COMPLETED:
10:00 AM
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 conducted a pre-licensing visit to follow up on corrections needed from the previous visit conducted on 12/15/21. LPA Flores met with Sako Manvelyan applicant and explained the reason for the visit.

LPA Flores and Sako Manvelyan applicant conducted a tour of the facility and observed the following corrections:

Facility has set up shaded sitting area in the backyard area.
Facility has blankets, comforters, set up in resident's beds in each room and in resident's closets.
Facility has set up a bed in each room, room #1 and #2 have been set up as single rooms and room #3 and #4 have been set up as shared rooms with all required furniture included but not limited to beds, dressers, night stands.
Facility has a current First Aid Safety Handbook.
Facility currently has all required PPE supplies sufficient for 30 days.
Facility has non-perishable food supplies sufficient for at least 7 days in kitchen cabinets.
Each resident's bathroom has been supplied with a basket with hygiene products for each resident, bathroom #2 has all required grab bars, and water temperature was tested at 114.4 degrees F. in bathroom #1, at 113.7 degrees F. in bathroom #2, at 113.5 degrees F. in bathroom #3, at 110.7 degrees F. bathroom #4, and at 110.0 degrees F. in bathroom #5.

Facility meets Title 22 Regulations for physical plant.

Exit interview was conducted with Sako Manvelyan applicant and a copy of this report was provided.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2022
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 1