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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603493
Report Date: 01/19/2023
Date Signed: 01/19/2023 11:34:12 AM


Document Has Been Signed on 01/19/2023 11:34 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:MOON LIGHT BOARDING CARE INCFACILITY NUMBER:
198603493
ADMINISTRATOR:VIKTORYA HAYRAPETYANFACILITY TYPE:
740
ADDRESS:120 N SIERRA BONITA AVETELEPHONE:
(818) 661-7333
CITY:PASADENASTATE: CAZIP CODE:
91106
CAPACITY:6CENSUS: 4DATE:
01/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:52 AM
MET WITH:Anna Petrosian - CaregiverTIME COMPLETED:
11:45 AM
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced annual visit at the facility with focus on the infection control domain, food, and medication review. LPA met with Anna Petrosian caregiver and explained the reason for the visit. Sako Manvelyan licensee arrived 15 minutes later.

The facility is licensed to served (6) non-ambulatory residents over the age of 60, of which (1) may be bedridden, with a hospice waiver for (4). The facility is a single home located in a residential neighborhood and consist of a living/dining room area, a kitchen, (4) resident bedrooms, (3) resident bathrooms, (1) staff/visitor's bathroom, a front porch, a backyard, and a detached garage.

LPA Flores conducted a tour with caregiver and administrator and observed the following:
Facility is clean and in good repair. Sufficient food supplies were observed for at least 2 days of perishables and 7 days of non-perishables, knives were locked in a drawer, and medication cabinet was locked in the kitchen area. Each resident bedroom has sufficient lighting, the required furniture and bedding. Each bathroom was observed with skid mats, and grab bars and in working condition, water temperature was tested in each bathroom between 107.7 - 119.6 degrees F., which is within the required 105-120 degrees F. Interlace Smoke/Carbon monoxide detectors were tested and in working condition, fire extinguisher located in the hallway outside the kitchen was last checked on 1/6/23. Outdoor area was observed a cover sitting area is located in the backyard. Cleaning supplies, PPE supplies, and additional food supplies are maintained in the lock garage. Sound devices in each exit door are in working condition. Signs on COVID symptoms and precautions are placed throughout the facility. Administrator certificate was observed #6058357740 exp: 1/6/23 renewal is pending all documents have been submitted to the department. LPA reviewed medication and files for 2 residents and 2 staff files. A copy of liability insurance was obtained during this visit.

No Deficiencies were noted during this visit.
Exit interview was conducted with Sako Manvelyan Licensee and a copy of this report was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
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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