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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881455
Report Date: 09/26/2023
Date Signed: 09/26/2023 09:50:57 AM


Document Has Been Signed on 09/26/2023 09:50 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:LUNA SENIOR LIVINGFACILITY NUMBER:
331881455
ADMINISTRATOR:MAMYAN, NARINEFACILITY TYPE:
740
ADDRESS:1361 E LUNA WAYTELEPHONE:
(818) 568-6812
CITY:PALM SPRINGSSTATE: CAZIP CODE:
92262
CAPACITY:6CENSUS: 0DATE:
09/26/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Administrator Narine Mamyan TIME COMPLETED:
10:55 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 (LPA) Cheryl Goodrich arrived at 9:07 AM. to conduct an announced Pre-Licensing visit. LPA met the Administrator Narine Mamyan at the front door and was granted entry. The purpose of today’s visit is to inspect the facility to ensure that the facility is following California Code of Regulations, Title 22, Division 6. Facility is approved for six (6) residents, 5 non-ambulatory, 1 bedridden with 0 residents in care.
Infection Control: The facility has an approved infection control plan and a surplus of supplies for infection control including but not limited to mask, gloves, gowns, first aid kit, and cleaning supplies.
Physical Plant and Environmental Safety: The facility temperature read at 76 degrees. The facility consists of 4 resident bedrooms: 2 bedrooms with 2 beds and 2 bedrooms with a single bed, and 3 bathrooms, living room, kitchen, and backyard. The bedrooms are furnished with lighting, closet space, and dresser. The beds are clean and have clean linens and the pathways are clean and clear of obstruction. The bathroom temperature read at 106 degrees within regulation requirements. The living room and kitchen are clean and clear of obstruction. The medications are stored in a locked cabinet in the kitchen and inaccessible to the resident. The facility and has a current fire clearance, smoke and carbon monoxide detectors and fire extinguishers and are in working order.
Personnel Records-Training: There are no staff currently hired at this time. The Administrator’s records are completed with fingerprint clearance, Health screening for TB, CPR/First Aid training, and in-service trainings.

(Continued on LIC809-C)
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl GoodrichTELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2023
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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: LUNA SENIOR LIVING
FACILITY NUMBER: 331881455
VISIT DATE: 09/26/2023
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
(Continued from LIC809)

Client Records-Incident Reports: The facility has no residents in care and does not have any client reports including but not limited to identification and emergency information, physician’s orders, MAR, and additional assessments. The facility does not handle the resident’s cash resources.
Client Rights-Information: The facility has client rights information posted in the facility.
Food Service: 7-day non-perishable and 2 day of perishable food supply was observed, and all food was properly stored and available.
Health- Related Services: The facility has a medication logbook (MAR), however no records are present due to no residents in care.
Disaster Preparedness: The facility has a disaster plan and has posted the evacuation plan, visible for staff and residents in care. The last fire drill was completed 08/11/23. The facility has emergency supply of food and water.
Summary: Based on today's visit, no deficiencies were observed at this time. The Pre-Licensing inspection has been completed. An exit interview was conducted with Administrator Narine Mamyan and a copy of this report was printed Signature below confirms receipt of these rights.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl GoodrichTELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2